Markers of Cardiovascular Risk Associated with Pregnancy

Maternal and neonatal outcomes in pregnant women undergoing cardiac surgery: a systematic review and meta-analysis

OBJECTIVE

Cardiac diseases that require surgical intervention present a unique challenge during pregnancy and may affect both maternal and neonatal outcomes. This systematic review and meta-analysis aimed to evaluate maternal and neonatal outcomes in pregnant females undergoing cardiac surgery.

METHODS

A comprehensive manual and electronic search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Sciences databases for studies published up to 31st May 2024. Eligible studies were required to report maternal and neonatal outcomes of women who underwent cardiac surgery during pregnancy. Random-effects meta-analysis was conducted to estimate pooled maternal and neonatal mortality proportions, and the results were presented as risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

Seventeen studies met the inclusion criteria, comprising a total sample size of 196 pregnant women who underwent cardiac surgery. Cardiac surgery during pregnancy was significantly (p < 0.001) linked to increased maternal and neonatal mortality, with pooled RR of 4.9% (CI: 2.1%-7.6%) and 26.5% (CI: 19.7%-33.4%), respectively.

CONCLUSION

This study highlights the significant risks associated with cardiac surgery during pregnancy, such as increased risk of maternal and neonatal mortality and higher incidence of preterm labor. Our findings underscore the importance of specialized care and multidisciplinary management for pregnant women with cardiac conditions. Further research is warranted to identify strategies for risk mitigation and improved outcomes in this vulnerable population.

Prepregnancy Adiposity, Adverse Pregnancy Outcomes, and Cardiovascular Disease Risk in Midlife

BACKGROUND

Prepregnancy obesity is a key modifiable risk factor for both adverse pregnancy outcomes (APOs) and cardiovascular disease (CVD). However, whether APOs represent a marker or mediator between body mass index (BMI) and CVD risk is unclear.

OBJECTIVES

This study sought to determine the extent to which the association between prepregnancy BMI and CVD risk factors in midlife is mediated by APOs.

METHODS

Pregnant participants aged ≥18 years enrolled at 28 weeks' gestation (range: 24-32 weeks) in the HAPO FUS (Hyperglycemia and Adverse Pregnancy Outcomes Follow-Up Study) without prepregnancy hypertension or diabetes were included in analyses. Participants had a follow-up visit 11.6 ± 1.3 years after delivery. Mediation analysis assessed the proportion of the association between self-reported prepregnancy BMI and CVD risk factors at follow-up (mean arterial pressure [MAP], triglycerides, and hemoglobin A1c [HbA1c]) mediated by gestational diabetes (GDM) and new-onset hypertensive disorders of pregnancy (HDP). Analyses were adjusted for maternal and gestational age, parity, field center, alcohol and smoking status in pregnancy, and fetal sex.

RESULTS

Among 4,269 study participants, mean maternal age was 30.1 ± 5.6 years, and 10.6% had prepregnancy obesity. GDM and new-onset HDP occurred in 13.8% and 10.7% of participants, respectively. Compared with those with a normal prepregnancy BMI, those with prepregnancy obesity had higher MAP (7.0 mm Hg; 95% CI: 6.0-8.1 mm Hg), triglycerides (28.5 mg/dL; 95% CI: 21.9-35.1 mg/dL), and HbA1c (0.3%; 95% CI: 0.2%-0.4%) at follow-up at a mean age of 41.7 ± 5.6 years. GDM partially mediated the association between obesity and HbA1c (24.6%; 95% CI: 20.9%-28.4%), whereas new-onset HDP partially mediated the association between obesity and MAP (12.4%; 95% CI: 10.6%-14.2%).

CONCLUSIONS

In this multinational cohort of pregnant individuals, APOs mediated a small proportion of the association between prepregnancy obesity and CVD risk in mid-life. Prioritizing weight management earlier in the life course before pregnancy may promote maternal and midlife cardiovascular health.

Sex-Specific Cardiovascular Risk Factors and Treatment in Females With T2DM and CVD: Developments and Knowledge Gaps

PURPOSE

There are large disparities in the impact of diabetes on cardiovascular disease (CVD) risk and outcomes by sex and gender. Achieving health equity requires understanding risks and medication efficacy in female patients, especially now, as novel pharmacologic treatments are transforming the diabetes and CVD treatment landscape. This review examines 2 bodies of research that can inform sex differences in CVD in patients with diabetes: female-specific risk factors for CVD and sex-related limitations of clinical trial research in evaluating novel diabetes and CVD treatments.

METHODS

Two literature searches were performed using Ovid Medline(R) All. The first retrieved manuscripts covering sex and gender differences related to CVD risk and therapies and diabetes. The second focused on randomized controlled trial data on sex/gender differences and GLP-1/SGLT-2/DPP-4 drugs.

RESULTS

Female-specific risk factors for CVD include early menarche, premature or early menopause, irregular cycles and polycystic ovary syndrome; pregnancy; adverse pregnancy outcomes; history of breast cancer; and autoimmune diseases. Clinical trials of novel pharmacological treatments for diabetes and CVD have undersampled female populations, and clinical characteristics of male and female participants have differed significantly. Thus, evidence to evaluate potential sex differences in treatment efficacy and side effects has been lacking.

CONCLUSION

To improve health of female patients with diabetes, sex-specific cardiovascular risk factors should be taken into account in screening and treatment decisions. Further, studies of cardiovascular and diabetes medications must ensure adequate representation by sex and report participant characteristics and outcomes by sex.

Short and long-term complications of hypertensive disorders of pregnancy: lifelong cardiovascular risks we cannot ignore

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy (HDP) pose a significant threat to maternal cardiovascular health, with emerging research shedding light on the enduring risks beyond the gestational period. This review highlights updates regarding cardiovascular risks associated with HDP and their implications for long-term health.

RECENT FINDINGS

Patients with a history of HDP are at an elevated risk of developing chronic hypertension, ischemic heart disease, stroke, valvular heart disease, and heart failure.Not surprisingly, patients with HDP experience higher rates of maternal and fetal adverse events in the antepartum and immediate postpartum periods, with high readmission rates for cardiovascular complications. The high risk of chronic hypertension after a HDP then leads to the development of subclinical disease over 5-10 years with overt cardiovascular disease becoming most prevalent in the decades following pregnancy. Early hypertension management in the antepartum and postpartum periods has lifelong health benefits and highlights the need for seamless postpartum transitions with close blood pressure monitoring and cardiovascular risk mitigation.

SUMMARY

HDP significantly increases the risk of short and long-term adverse cardiovascular events. Integrated healthcare models that assess and address postpartum cardiovascular risk are necessary to improve the cardiovascular health and longevity of those effected by HDP.

Association between gestational diabetes and cardiovascular disease within 24 months postpartum

BACKGROUND

Cardiovascular disease is the leading cause of death among women in the United States. It is well established that gestational diabetes mellitus is associated with an overall lifetime increased risk of cardiometabolic disease, even among those without intercurrent type 2 diabetes. However, the association between gestational diabetes mellitus and short-term risk of cardiovascular disease is unclear. Establishing short-term risks of cardiovascular disease for patients with gestational diabetes mellitus has significant potential to inform early screening and targeted intervention strategies to reduce premature cardiovascular morbidity among women.

OBJECTIVE

This study aimed to compare the risk of cardiovascular disease diagnosis in the first 24 months postpartum between patients with and without gestational diabetes mellitus.

STUDY DESIGN

Our longitudinal population-based study included pregnant individuals with deliveries from 2007 to 2019 in the Maine Health Data Organization's All Payer Claims Database. We excluded records with gestational age <20 weeks, non-Maine residence, multifetal gestation, no insurance in the month of delivery or the 3 months before pregnancy, an implausibly short interval until next pregnancy (<60 days), pregestational diabetes mellitus, and any prepregnancy diagnosis of the cardiovascular conditions being examined postpartum. Gestational diabetes mellitus and cardiovascular disease (heart failure, ischemic heart disease, arrhythmia/cardiac arrest, cardiomyopathy, cerebrovascular disease/stroke, and new chronic hypertension) were identified by International Classification of Diseases 9/10 diagnosis codes. Cox proportional hazards models were used to estimate hazard ratios, adjusting for potential confounding factors. We assessed whether the association between gestational diabetes mellitus and chronic hypertension was mediated by intercurrent diabetes mellitus.

RESULTS

Among the 84,746 pregnancies examined, the cumulative risk of cardiovascular disease within 24 months postpartum for those with vs without gestational diabetes mellitus was 0.13% vs 0.20% for heart failure, 0.16% vs 0.14% for ischemic heart disease, 0.60% vs 0.44% for cerebrovascular disease/stroke, 0.22% vs 0.16% for arrhythmia/cardiac arrest, 0.20% vs 0.20% for cardiomyopathy, and 4.19% vs 1.83% for new chronic hypertension. After adjusting for potential confounders, those with gestational diabetes had an increased risk of new chronic hypertension (adjusted hazard ratio, 1.56; 95% confidence interval, 1.32-1.86) within the first 24 months postpartum compared with those without gestational diabetes. There was no association between gestational diabetes and ischemic heart disease (adjusted hazard ratio, 0.75; 95% confidence interval, 0.34-1.65), cerebrovascular disease/stroke (adjusted hazard ratio, 1.13; 95% confidence interval, 0.78-1.66), arrhythmia/cardiac arrest (adjusted hazard ratio, 1.16; 95% confidence interval, 0.59-2.29), or cardiomyopathy (adjusted hazard ratio, 0.75; 95% confidence interval, 0.40-1.41) within the first 24 months postpartum. Those with gestational diabetes appeared to have a decreased risk of heart failure within 24 months postpartum (adjusted hazard ratio, 0.45; 95% confidence interval, 0.21-0.98). Our mediation analyses estimated that 28% of the effect of gestational diabetes on new chronic hypertension was mediated through intercurrent diabetes mellitus.

CONCLUSION

Patients with gestational diabetes mellitus have a significantly increased risk of new chronic hypertension as early as 24 months postpartum. Most of this effect was not due to the development of diabetes mellitus. Our findings suggest that all women with gestational diabetes need careful monitoring and screening for new chronic hypertension in the first 2 years postpartum.