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Garrud TAC, Teulings NEWD, Niu Y, Skeffington KL, Beck C, Itani N, Conlon FG, Botting KJ, Nicholas LM, Tong W, Derks JB, Ozanne SE, Giussani DA. Molecular mechanisms underlying adverse effects of dexamethasone and betamethasone in the developing cardiovascular system. FASEB J 2023; 37:e22887. [PMID: 37132324 PMCID: PMC10946807 DOI: 10.1096/fj.202200676rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 03/02/2023] [Accepted: 03/09/2023] [Indexed: 05/04/2023]
Abstract
Antenatal glucocorticoids accelerate fetal lung maturation and reduce mortality in preterm babies but can trigger adverse effects on the cardiovascular system. The mechanisms underlying off-target effects of the synthetic glucocorticoids mostly used, Dexamethasone (Dex) and Betamethasone (Beta), are unknown. We investigated effects of Dex and Beta on cardiovascular structure and function, and underlying molecular mechanism using the chicken embryo, an established model system to isolate effects of therapy on the developing heart and vasculature, independent of effects on the mother or placenta. Fertilized eggs were treated with Dex (0.1 mg kg-1 ), Beta (0.1 mg kg-1 ), or water vehicle (Control) on embryonic day 14 (E14, term = 21 days). At E19, biometry, cardiovascular function, stereological, and molecular analyses were determined. Both glucocorticoids promoted growth restriction, with Beta being more severe. Beta compared with Dex induced greater cardiac diastolic dysfunction and also impaired systolic function. While Dex triggered cardiomyocyte hypertrophy, Beta promoted a decrease in cardiomyocyte number. Molecular changes of Dex on the developing heart included oxidative stress, activation of p38, and cleaved caspase 3. In contrast, impaired GR downregulation, activation of p53, p16, and MKK3 coupled with CDK2 transcriptional repression linked the effects of Beta on cardiomyocyte senescence. Beta but not Dex impaired NO-dependent relaxation of peripheral resistance arteries. Beta diminished contractile responses to potassium and phenylephrine, but Dex enhanced peripheral constrictor reactivity to endothelin-1. We conclude that Dex and Beta have direct differential detrimental effects on the developing cardiovascular system.
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Affiliation(s)
- Tessa A. C. Garrud
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Noor E. W. D. Teulings
- Institute of Metabolic Science‐Metabolic Research Laboratories, MRC Metabolic Diseases UnitUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
| | - Youguo Niu
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Katie L. Skeffington
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Christian Beck
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Nozomi Itani
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Fiona G. Conlon
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Kimberley J. Botting
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Lisa M. Nicholas
- Institute of Metabolic Science‐Metabolic Research Laboratories, MRC Metabolic Diseases UnitUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
| | - Wen Tong
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Jan B. Derks
- Department of Perinatal MedicineUniversity Medical CentreUtrechtNetherlands
| | - Susan E. Ozanne
- Institute of Metabolic Science‐Metabolic Research Laboratories, MRC Metabolic Diseases UnitUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
- BHF Cardiovascular Centre for Research ExcellenceUniversity of CambridgeCambridgeUK
- Strategic Research Initiative in ReproductionUniversity of CambridgeCambridgeUK
- Centre for Trophoblast ResearchUniversity of CambridgeCambridgeUK
| | - Dino A. Giussani
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
- BHF Cardiovascular Centre for Research ExcellenceUniversity of CambridgeCambridgeUK
- Strategic Research Initiative in ReproductionUniversity of CambridgeCambridgeUK
- Centre for Trophoblast ResearchUniversity of CambridgeCambridgeUK
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Kane AD, Herrera EA, Niu Y, Camm EJ, Allison BJ, Tijsseling D, Lusby C, Derks JB, Brain KL, Bronckers IM, Cross CM, Berends L, Giussani DA. Combined Statin and Glucocorticoid Therapy for the Safer Treatment of Preterm Birth. Hypertension 2023; 80:837-851. [PMID: 36724801 PMCID: PMC10017302 DOI: 10.1161/hypertensionaha.122.19647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 01/03/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Prematurity is strongly associated with poor respiratory function in the neonate. Rescue therapies include treatment with glucocorticoids due to their anti-inflammatory and maturational effects on the developing lung. However, glucocorticoid treatment in the infant can increase the risk of long-term cardiovascular complications including hypertension, cardiac, and endothelial dysfunction. Accumulating evidence implicates a molecular link between glucocorticoid excess and depletion of nitric oxide (NO) bioavailability as a mechanism underlying the detrimental effects of postnatal steroids on the heart and circulation. Therefore, combined glucocorticoid and statin therapy, by increasing NO bioavailability, may protect the developing cardiovascular system while maintaining beneficial effects on the lung. METHODS We investigated combined glucocorticoid and statin therapy using an established rodent model of prematurity and combined experiments of cardiovascular function in vivo, with those in isolated organs as well as measurements at the cellular and molecular levels. RESULTS We show that neonatal glucocorticoid treatment increases the risk of later cardiovascular dysfunction in the offspring. Underlying mechanisms include decreased circulating NO bioavailability, sympathetic hyper-reactivity, and NO-dependent endothelial dysfunction. Combined neonatal glucocorticoid and statin therapy protects the developing cardiovascular system by normalizing NO and sympathetic signaling, without affecting pulmonary maturational or anti-inflammatory effects of glucocorticoids. CONCLUSIONS Therefore, combined glucocorticoid and statin therapy may be safer than glucocorticoids alone for the treatment of preterm birth.
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Affiliation(s)
- Andrew D. Kane
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
| | - Emilio A. Herrera
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile (E.A.H.)
| | - Youguo Niu
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
- The Cambridge BHF Centre for Research Excellence, Cambridge, United Kingdom (Y.N., D.A.G.)
- The Cambridge Strategic Research Initiative in Reproduction, Cambridge, United Kingdom (Y.N., D.A.G.)
| | - Emily J. Camm
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia (E.J.C., B.J.A.)
| | - Beth J. Allison
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia (E.J.C., B.J.A.)
| | - Deodata Tijsseling
- Perinatal Center, University Medical Center, Utrecht, the Netherlands (D.T., J.B.D.)
| | - Ciara Lusby
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
| | - Jan B. Derks
- Perinatal Center, University Medical Center, Utrecht, the Netherlands (D.T., J.B.D.)
| | - Kirsty L. Brain
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
| | - Inge M. Bronckers
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, the Netherlands (I.M.B.)
| | - Christine M. Cross
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
| | - Lindsey Berends
- Institute of Metabolic Science, University of Cambridge Metabolic Research Laboratories, Addenbrooke’s Hospital, Cambridge, United Kingdom (L.B.)
| | - Dino A. Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom (A.D.K., E.A.H., Y.N., E.J.C., B.J.A., C.L., K.L.B., C.M.C., D.A.G.)
- The Cambridge BHF Centre for Research Excellence, Cambridge, United Kingdom (Y.N., D.A.G.)
- The Cambridge Strategic Research Initiative in Reproduction, Cambridge, United Kingdom (Y.N., D.A.G.)
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Smith KLM, Swiderska A, Lock MC, Graham L, Iswari W, Choudhary T, Thomas D, Kowash HM, Desforges M, Cottrell EC, Trafford AW, Giussani DA, Galli GLJ. Chronic developmental hypoxia alters mitochondrial oxidative capacity and reactive oxygen species production in the fetal rat heart in a sex-dependent manner. J Pineal Res 2022; 73:e12821. [PMID: 35941749 PMCID: PMC9540814 DOI: 10.1111/jpi.12821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/28/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022]
Abstract
Insufficient oxygen supply (hypoxia) during fetal development leads to cardiac remodeling and a predisposition to cardiovascular disease in later life. Previous work has shown hypoxia causes oxidative stress in the fetal heart and alters the activity and expression of mitochondrial proteins in a sex-dependent manner. However, the functional effects of these modifications on mitochondrial respiration remain unknown. Furthermore, while maternal antioxidant treatments are emerging as a promising new strategy to protect the hypoxic fetus, whether these treatments convey similar protection to cardiac mitochondria in the male or female fetus has not been investigated. Therefore, using an established rat model, we measured the sex-dependent effects of gestational hypoxia and maternal melatonin treatment on fetal cardiac mitochondrial respiration, reactive oxygen species (ROS) production, and lipid peroxidation. Pregnant Wistar rats were subjected to normoxia or hypoxia (13% oxygen) during gestational days (GDs) 6-20 (term ~22 days) with or without melatonin treatment (5 µg/ml in maternal drinking water). On GD 20, mitochondrial aerobic respiration and H2 O2 production were measured in fetal heart tissue, together with lipid peroxidation and citrate synthase (CS) activity. Gestational hypoxia reduced maternal body weight gain (p < .01) and increased placental weight (p < .05) but had no effect on fetal weight or litter size. Cardiac mitochondria from male but not female fetuses of hypoxic pregnancy had reduced respiratory capacity at Complex II (CII) (p < .05), and an increase in H2 O2 production/O2 consumption (p < .05) without any changes in lipid peroxidation. CS activity was also unchanged in both sexes. Despite maternal melatonin treatment increasing maternal and fetal plasma melatonin concentration (p < .001), melatonin treatment had no effect on any of the mitochondrial parameters investigated. To conclude, we show that gestational hypoxia leads to ROS generation from the mitochondrial electron transport chain and affects fetal cardiac mitochondrial respiration in a sex-dependent manner. We also show that maternal melatonin treatment had no effect on these relationships, which has implications for the development of future therapies for hypoxic pregnancies.
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Affiliation(s)
- Kerri L. M. Smith
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Agnieszka Swiderska
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Mitchell C. Lock
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Lucia Graham
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Wulan Iswari
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Tashi Choudhary
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Donna Thomas
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Hager M. Kowash
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Michelle Desforges
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Elizabeth C. Cottrell
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Andrew W. Trafford
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Dino A. Giussani
- Department of Physiology Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Gina L. J. Galli
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
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Hansell JA, Richter HG, Camm EJ, Herrera EA, Blanco CE, Villamor E, Patey OV, Lock MC, Trafford AW, Galli GLJ, Giussani DA. Maternal melatonin: Effective intervention against developmental programming of cardiovascular dysfunction in adult offspring of complicated pregnancy. J Pineal Res 2022; 72:e12766. [PMID: 34634151 DOI: 10.1111/jpi.12766] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/16/2021] [Accepted: 08/26/2021] [Indexed: 12/01/2022]
Abstract
Adopting an integrative approach, by combining studies of cardiovascular function with those at cellular and molecular levels, this study investigated whether maternal treatment with melatonin protects against programmed cardiovascular dysfunction in the offspring using an established rodent model of hypoxic pregnancy. Wistar rats were divided into normoxic (N) or hypoxic (H, 10% O2 ) pregnancy ± melatonin (M) treatment (5 μg·ml-1 .day-1 ) in the maternal drinking water. Hypoxia ± melatonin treatment was from day 15-20 of gestation (term is ca. 22 days). To control for possible effects of maternal hypoxia-induced reductions in maternal food intake, additional dams underwent pregnancy under normoxic conditions but were pair-fed (PF) to the daily amount consumed by hypoxic dams from day 15 of gestation. In one cohort of animals from each experimental group (N, NM, H, HM, PF, PFM), measurements were made at the end of gestation. In another, following delivery of the offspring, investigations were made at adulthood. In both fetal and adult offspring, fixed aorta and hearts were studied stereologically and frozen hearts were processed for molecular studies. In adult offspring, mesenteric vessels were isolated and vascular reactivity determined by in-vitro wire myography. Melatonin treatment during normoxic, hypoxic or pair-fed pregnancy elevated circulating plasma melatonin in the pregnant dam and fetus. Relative to normoxic pregnancy, hypoxic pregnancy increased fetal haematocrit, promoted asymmetric fetal growth restriction and resulted in accelerated postnatal catch-up growth. Whilst fetal offspring of hypoxic pregnancy showed aortic wall thickening, adult offspring of hypoxic pregnancy showed dilated cardiomyopathy. Similarly, whilst cardiac protein expression of eNOS was downregulated in the fetal heart, eNOS protein expression was elevated in the heart of adult offspring of hypoxic pregnancy. Adult offspring of hypoxic pregnancy further showed enhanced mesenteric vasoconstrictor reactivity to phenylephrine and the thromboxane mimetic U46619. The effects of hypoxic pregnancy on cardiovascular remodelling and function in the fetal and adult offspring were independent of hypoxia-induced reductions in maternal food intake. Conversely, the effects of hypoxic pregnancy on fetal and postanal growth were similar in pair-fed pregnancies. Whilst maternal treatment of normoxic or pair-fed pregnancies with melatonin on the offspring cardiovascular system was unremarkable, treatment of hypoxic pregnancies with melatonin in doses lower than those recommended for overcoming jet lag in humans enhanced fetal cardiac eNOS expression and prevented all alterations in cardiovascular structure and function in fetal and adult offspring. Therefore, the data support that melatonin is a potential therapeutic target for clinical intervention against developmental origins of cardiovascular dysfunction in pregnancy complicated by chronic fetal hypoxia.
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Affiliation(s)
- Jeremy A Hansell
- Department of Physiology Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Hans G Richter
- Facultad de Medicina, Instituto de Anatomía, Histología y Patología, Universidad Austral de Chile, Valdivia, Chile
| | - Emily J Camm
- Department of Physiology Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Emilio A Herrera
- Programa de Fisiopatología, Facultad de Medicina, Instituto de Ciencias Biomédicas (ICBM), Universidad de Chile, Santiago, Chile
| | - Carlos E Blanco
- National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland
| | - Eduardo Villamor
- Department of Pediatrics, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Olga V Patey
- Department of Physiology Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Mitchell C Lock
- Division of Cardiovascular Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Andrew W Trafford
- Division of Cardiovascular Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Gina L J Galli
- Division of Cardiovascular Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Dino A Giussani
- Department of Physiology Development and Neuroscience, University of Cambridge, Cambridge, UK
- Cambridge BHF Centre for Research Excellence, Cambridge, UK
- Cambridge Strategic Research Initiative in Reproduction, Cambridge, UK
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Abstract
Heart disease remains one of the greatest killers. In addition to genetics and traditional lifestyle risk factors, we now understand that adverse conditions during pregnancy can also increase susceptibility to cardiovascular disease in the offspring. Therefore, the mechanisms by which this occurs and possible preventative therapies are of significant contemporary interest to the cardiovascular community. A common suboptimal pregnancy condition is a sustained reduction in fetal oxygenation. Chronic fetal hypoxia results from any pregnancy with increased placental vascular resistance, such as in preeclampsia, placental infection, or maternal obesity. Chronic fetal hypoxia may also arise during pregnancy at high altitude or because of maternal respiratory disease. This article reviews the short- and long-term effects of hypoxia on the fetal cardiovascular system, and the importance of chronic fetal hypoxia in triggering a developmental origin of future heart disease in the adult progeny. The work summarizes evidence derived from human studies as well as from rodent, avian, and ovine models. There is a focus on the discovery of the molecular link between prenatal hypoxia, oxidative stress, and increased cardiovascular risk in adult offspring. Discussion of mitochondria-targeted antioxidant therapy offers potential targets for clinical intervention in human pregnancy complicated by chronic fetal hypoxia.
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Affiliation(s)
- Dino A Giussani
- Department of Physiology, Development, and Neuroscience; The Barcroft Centre; Cambridge Cardiovascular British Heart Foundation Centre for Research Excellence; and Cambridge Strategic Research Initiative in Reproduction, University of Cambridge, UK
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Vahedian-Azimi A, Makvandi S, Banach M, Reiner Ž, Sahebkar A. Fetal toxicity associated with statins: A systematic review and meta-analysis. Atherosclerosis 2021; 327:59-67. [PMID: 34044205 DOI: 10.1016/j.atherosclerosis.2021.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/08/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS Statins are the drugs of choice for decreasing elevated low-density lipoprotein cholesterol. Based mostly on animal studies and case reports, they are forbidden to pregnant women and in the preconception period because of their possible teratogenic effects, for which causality has never been proven. The aim of this study was to systematically review the existing studies and to perform a meta-analysis on this topic. METHODS The databases PubMed/MEDLINE, Scopus, and Web of Science were searched since the inception until May 16, 2020. The risk of bias for each clinical trial was evaluated using the Cochrane handbook criteria for systematic reviews. The National Institutes of Health (NIH) quality assessment tool was used for the evaluation of cohort and cross-sectional studies. Meta-analysis was performed on the extracted data. Heterogeneity was assessed using I2 measure and Cochrane's Q statistic. We calculated a pooled estimate of odds ratio (OR) and 95% confidence intervals (CI) using a random-effects model. RESULTS 23 studies (nine cohort studies, six case reports, six case series, one population-based case-referent study and one clinical trial) with 1,276,973 participants were included in the systematic review and 6 of them (n = 1,267,240 participants) were included in meta-analysis. The results of the critical review did not suggest a clear-cut answer to the question whether statin treatment during pregnancy is associated with an increased rate of birth defects or not, while the results of the meta-analysis indicated that statin use does not increase birth defects [OR (95%CI): 1.48 (0.90, 2.42), p = 0.509], including cardiac anomalies [2.53 (0.81, 7.93), p = 0.112] and other congenital anomalies [1.19 (0.70, 2.03), p = 0.509)]. CONCLUSIONS We observed no significant increase of birth defects after statin therapy. Thus, there is still no undoubtful evidence that statin treatment during pregnancy is teratogenic, and this issue still needs to be investigated, especially there are more and more pregnant women at high CVD risk that could have benefited from the statin therapy.
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Affiliation(s)
- Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Somayeh Makvandi
- Department of Midwifery, School of Nursing and Midwifery, Islamic Azad University Ahvaz Branch, Ahvaz, Iran.
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland; Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Željko Reiner
- Department of Internal Diseases University Hospital Center Zagreb School of Medicine, Zagreb University, Zagreb, Croatia
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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