History of adverse pregnancy outcomes associated with image-identified coronary artery disease

1. In this population-based cross-sectional study, among 10 528 Swedish women undergoing coronary computed tomography (CT) angiography, there was a statistically significant association between a history of adverse pregnancy outcomes and image-identified coronary artery disease, compared to the reference group, including preeclampsia (prevalence 36.5% vs 28.3%) and gestational hypertension (prevalence 40.9% vs 28.3%).

2. The prevalence of any coronary atherosclerosis in women with a history of any adverse pregnancy outcome was 32.1% when compared with the reference group (prevalence difference 3.8%).

Evidence Rating Level: 2 (Good)

Study Rundown: Coronary artery disease (CAD) is a leading cause of death for women and men globally. Risk factors for CAD that are unique to women include adverse pregnancy outcomes such as preeclampsia, gestational hypertension, preterm delivery and gestational diabetes, among other factors. Coronary CT angiography (CCTA) provides noninvasive visualization of the coronary arteries and is an effective screening tool for CAD. The objective of this study was to assess associations between a history of adverse pregnancy outcomes and CAD through CCTA screening. This was a cross-sectional, population-based cohort that consisted of 10 528 Swedish women with 1 or more deliveries in 1973 or later. Exposures included the following adverse pregnancy outcomes: preeclampsia, gestation hypertension, preterm delivery, small-for-gestational-age infant, and gestational diabetes. The main outcomes were CCTA indexes, including coronary atherosclerosis, significant stenosis, noncalcified plaque, segment score of 4 or greater, and coronary artery calcium score greater than 100. The prevalence of any coronary artery atherosclerosis in women with a history of adverse pregnancy outcomes was 32.1%. For preeclampsia, the highest prevalence difference, at 8%, was observed for any coronary atherosclerosis, and the highest prevalence ratio, at 2.46, was observed for significant stenosis. A limitation of this study was that information on lifestyle factors and comorbidities, such as a history of smoking, and gestational diabetes at the time of pregnancy, was not available for all women. A major strength, however, was the use of a large cohort that included pregnancy history for women spanning over 5 decades. This study highlights a statistically significant association between a history of adverse pregnancy outcomes and CCTA-identified CAD, including among women estimated to otherwise be at low risk for cardiovascular disease.

Click to read the study in JAMA

Click to read an accompanying editorial in JAMA

Relevant Reading: Preeclampsia and future cardiovascular health: a systematic review and meta-analysis

In-Depth [cross-sectional study]: This study assessed the association between a history of adverse pregnancy outcomes and image-identified coronary artery disease. A total of 10 528 Swedish women with 1 or more deliveries in 1973 or later, ascertained through the Swedish National Medical Birth Register, were included in this study. Among the cohort of included women, a median 29.6 (IQR, 25.0-34.9) years after first registered delivery,18.9% of women had a history of adverse pregnancy outcomes, in particular, 1.4% had gestational diabetes, and 9.5% had preterm delivery. This study found that the prevalence of any coronary atherosclerosis in women with a history of adverse pregnancy outcomes was 32.1% (95% CI, 20.0% – 34.2%) which was significantly higher when compared with the reference group (prevalence difference, 3.8% [95% CI, 1.6% – 6.1%]; prevalence ration, 1.14 [95% CI, 1.06 – 1.22]).  Gestational hypertension and preeclampsia were both significantly associated with a higher similar prevalence of all outcome indexes. Preeclampsia had the highest observed prevalence difference 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 an adjusted model, the 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.

Image: PD

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