Premature cardiovascular disease following a history of hypertensive disorder of pregnancy

STEMI, Revascularization, and Peak Troponin by Adverse Pregnancy Outcomes in Women With Myocardial Infarction

Background

Women with a history of adverse pregnancy outcomes have a higher risk of coronary heart disease. Emerging evidence suggests that women with a history of preeclampsia have a different pattern of overall coronary atherosclerosis and that they at the time of myocardial infarction (MI) more frequently present with ST-segment elevation MI (STEMI) compared to women with no such history.

Objectives

The purpose of this study was to determine whether among women with MI, those with a history of adverse pregnancy outcomes are more likely to present with STEMI or other clinical characteristics indicating a more severe myocardial injury.

Methods

The study sample consisted of 8,320 women aged ≤65 years with first MI in Sweden 2007 to 2022. Regression models were used to estimate the association between adverse pregnancy outcomes (hypertensive disorders of pregnancy [non-preeclamptic hypertension and preeclampsia], small for gestational age [SGA] infant, and preterm delivery) and STEMI, invasive revascularization, and high troponin, while considering known predictors of coronary heart disease.

Results

In total, 3,128 (38%) of women suffered STEMI. The adjusted OR of presenting with STEMI were higher in women with a history of preterm preeclampsia (OR: 1.40; 95% CI: 1.05-1.88), or an SGA infant (OR: 1.30; 95% CI: 1.13-1.50) compared to women with no such history, as well as for in-hospital revascularization. Stratified by infarct type, troponin levels did not differ by adverse pregnancy outcome history.

Conclusions

Among women with a first MI, a history of preterm preeclampsia or SGA infant were associated with STEMI and invasive revascularization.

Cardiovascular morbidity and mortality following hypertensive disorders of pregnancy

OBJECTIVES

To determine whether hypertensive disorders of pregnancy (HDP) are associated with maternal coronary artery disease (CAD) and other cardiovascular (CV) diseases within 10-20 years following delivery.

STUDY DESIGN

Retrospective cohort including all women who delivered ≥ 1 pregnancy ≥ 20 weeks' gestation within a single health system from 1998 to 2008. We excluded those with CV risk factors preceding first delivery or with no follow-up after delivery. The exposure of interest was any HDP, determined by ICD coding.

MAIN OUTCOME MEASURES

The primary outcome was a composite of ICD codes for CAD, peripheral vascular disease, and CV events (myocardial infarction, stroke, and death). Multivariable Cox proportional hazards estimated the association between exposure and outcomes. A nested cohort of women who underwent cardiac catheterization had a primary outcome of angiographic CAD, and multivariable logistic regression estimated the association between HDP and CAD.

RESULTS

Of 33,959 women included, 2,385 women had HDP. HDP was associated with the composite outcome (adjusted HR 1.50, 95 % CI 1.11, 2.03). There was a significant difference in event-free survival between groups (p = 0.003) with a median follow-up of 17.3 years. 592 women (1.7 %) underwent cardiac catheterization: 20 of 90 women with HDP had CAD (22.2 %) on angiography vs 49 of 502 without HDP (9.8 %, p < 0.001). HDP was associated with angiographic CAD (adjusted OR 2.08, 95 % CI 1.05, 4.11).

CONCLUSIONS

Women with HDP had twice the incidence of CAD on angiography compared to parous women without HDP. Obstetric history may inform the decision to perform cardiac catheterization in relatively young women.

Breastfeeding initiation and duration among people with mild chronic hypertension: a secondary analysis of the Chronic Hypertension and Pregnancy trial

BACKGROUND

Increased duration of breastfeeding improves maternal cardiovascular health and may be especially beneficial in high-risk populations, such as those with chronic hypertension. Others have shown that individuals with hypertension are less likely to breastfeed, and there has been limited research aimed at supporting breastfeeding goals in this population. The impact of perinatal blood pressure control on breastfeeding outcomes among people with chronic hypertension is unknown.

OBJECTIVE

This study aimed to evaluate whether breastfeeding initiation and short-term duration assessed at the postpartum clinic visit differed according to perinatal blood pressure treatment strategy (targeting blood pressure <140/90 mm Hg vs reserving antihypertensive treatment for blood pressure ≥160/105 mm Hg).

STUDY DESIGN

We performed a secondary analysis of the Chronic Hypertension and Pregnancy trial. This was an open-label, multicenter, randomized trial where pregnant participants with mild chronic hypertension were randomized to receive antihypertensive medications with goal blood pressure <140/90 mm Hg (active treatment) or deferred treatment until blood pressure ≥160/105 mm Hg (control). The primary outcome was initiation and duration of breastfeeding, assessed at the postpartum clinic visit. We performed bivariate analyses and log-binomial and cumulative logit regression models, adjusting models for variables that were unbalanced in bivariate analyses. We performed additional analyses to explore the relationship between breastfeeding duration and blood pressure measurements at the postpartum visit.

RESULTS

Of the 2408 participants from the Chronic Hypertension and Pregnancy trial, 1444 (60%) attended the postpartum study visit and provided breastfeeding information. Participants in the active treatment group had different body mass index class distribution and earlier gestational age at enrollment, and (by design) were more often discharged on antihypertensives. Breastfeeding outcomes did not differ significantly by treatment group. In the active and control treatment groups, 563 (77.5%) and 561 (78.1%) initiated breastfeeding, and mean durations of breastfeeding were 6.5±2.3 and 6.3±2.1 weeks, respectively. The probability of ever breastfeeding (adjusted relative risk, 0.99; 95% confidence interval, 0.93-1.05), current breastfeeding at postpartum visit (adjusted relative risk, 1.01; 95% confidence interval, 0.94-1.10), and weeks of breastfeeding (adjusted odds ratio, 0.87; 95% confidence interval, 0.68-1.12) did not differ by treatment group. Increased duration (≥2 vs <2 weeks) of breastfeeding was associated with slightly lower blood pressure measurements at the postpartum visit, but these differences were not significant in adjusted models.

CONCLUSION

In a secondary analysis of the cohort of Chronic Hypertension and Pregnancy trial participants who attended the postpartum study visit and provided breastfeeding information (60% of original trial participants), breastfeeding outcomes did not differ significantly by treatment group. This suggests that maintaining goal blood pressure <140/90 mm Hg throughout the perinatal period is associated with neither harm nor benefit for short-term breastfeeding goals. Further study is needed to understand long-term breastfeeding outcomes among individuals with chronic hypertension and how to support this population in achieving their breastfeeding goals.

Characteristics of Premature Myocardial Infarction Among Women With Prior Adverse Pregnancy Outcomes

BACKGROUND

Adverse pregnancy outcomes (APOs), hypertensive disorders of pregnancy, gestational diabetes mellitus, and preterm birth are associated with ischemic heart disease in later life.

OBJECTIVES

The authors aimed to study the features of premature myocardial infarction (MI) among women with and without prior APOs.

METHODS

We performed a retrospective analysis of women with premature MI (<65 years of age) referred for left heart catheterization matched with a database of abstracted pregnancy data. We compared MI characteristics and epicardial coronary anatomy between women with and without APOs during their index pregnancy and evaluated time from delivery to MI.

RESULTS

Of 391 women with premature MI and associated coronary angiography (age: 49 ± 8 years), 154 (39%) had a prior APO (hypertensive disorders of pregnancy n = 78, preeclampsia n = 35, gestational diabetes mellitus n = 28, and preterm birth n = 48). Women with APO history had a higher prevalence of diabetes (33% vs 16% without APO; P = 0.001) and presented earlier with MI following delivery (19.6 [IQR: 14.3-23.5] years vs those without APO 21.5 [IQR: 17.0-25.4] years; P = 0.012), driven by preeclampsia (17.1 [IQR: 12.7-22.4] years, P = 0.010). Women with and without APOs had similar MI features including rates of ST-segment elevation MI, obstructive and multi-vessel coronary artery disease, percutaneous coronary intervention, and shock.

CONCLUSIONS

Among women with premature MIs, 39% had a history of an APO. Women with APO history presented sooner after pregnancy but had similar MI characteristics vs those without APOs. Pregnancy history may identify women who warrant early, aggressive cardiovascular disease prevention.

Study protocol for the sheMATTERS study (iMproving cArdiovascular healTh in new moThERS): a randomized behavioral trial assessing the effect of a self-efficacy enhancing breastfeeding intervention on postpartum blood pressure and breastfeeding continuation in women with hypertensive disorders of pregnancy

BACKGROUND

Individuals with hypertensive disorders of pregnancy (HDP) have an elevated lifetime risk of chronic hypertension, metabolic syndrome, and premature cardiovascular disease. Because breastfeeding duration and exclusivity have been associated in observational studies with improved cardiovascular health, optimizing breastfeeding in those with HDP might be an unrealized cardio-prevention approach, in particular because individuals with HDP have more breastfeeding challenges. Breastfeeding supportive interventions targeting one's breastfeeding self-efficacy have been shown to improve breastfeeding rates.

METHODS

We designed an open-label, multi-center 1:1 randomized behavioral trial to test whether a previously validated self-efficacy enhancing breastfeeding intervention can improve breastfeeding duration and/or exclusivity, and lower postpartum blood pressure at 12 months. Randomization is computer-generated and stratified by site (four hospitals in Montreal, Quebec and one hospital in Kingston, Ontario; all in Canada). Included are breastfeeding participants with HDP (chronic/gestational hypertension or preeclampsia) who delivered a live singleton infant at > 34 weeks, speak English or French, and have no contraindications to breastfeeding. Informed and written consent is obtained at hospitalization for delivery or a re-admission with hypertension within 1 week of discharge. Participants assigned to the intervention group receive a breastfeeding self-efficacy-based intervention delivered by a trained lactation consultant in hospital, with continued reactive/proactive support by phone or text message for up to 6 months postpartum. Regardless of group assignment, participants are followed for self-reported outcomes, automated office blood pressure, and home blood pressure at several time points with end of follow-up at 12 months.

DISCUSSION

This study will assess whether an intensive nurse-led behavioral intervention can improve breastfeeding rates and, in turn, postpartum blood pressure - an early marker for atherosclerotic cardiovascular disease. If effective, this form of enhanced breastfeeding support, along with closer BP and metabolic surveillance, can be implemented broadly in individuals lactating after HDP.

TRIAL REGISTRATION

ClinicalTrials.gov, # NCT04580927 , registered on Oct 9, 2020.

Cardiovascular Disease in Women: What the Radiologist Needs to Know

BACKGROUND

 Sex-specific disparities are well documented for cardiovascular disease (CVD). There are differences in physiology and pathophysiology, pain perception, spectrum of disease, risk, therapeutic aspects, prognosis, and outcome. CVD represents a broad spectrum of disorders. This review focuses on cardiovascular and cardiac pathology.

METHOD

 This review summarizes the current state of the literature on cardiovascular disease in women from a radiological viewpoint. It aims to provide a deeper understanding of these differences and thereby alerts the reader to the potential of CT and MRI for diagnosing CVD in women. Special attention is paid to disparities in the underlying physiological and pathophysiological processes, clinical presentation, and the quality of care to provide a deep understanding of the topic. Cardiovascular and cardiac pathologies with a sex-specific pattern of disease are presented and typical CT and MRI findings are arranged and illustrated with imaging findings.

RESULTS AND CONCLUSION

 Sex-specific differences are not only sex hormonal in nature but are rooted in the epigenome and encompass a multitude of physiological systems. In fact, cardiovascular disease shows sex-specific characteristics spanning from incidence to clinical presentation, course of disease, and prognosis. This is of significance regarding pretest probabilities, the power of tests, imaging strategies, and interpretation of imaging results. Key sex-specific issues encompass obstructive and non-obstructive coronary artery disease (CAD), microvascular angina, myocardial infarction with non-obstructive CAD, and coronary artery dissection. Sex-specific patterns are also noted in myocardial disease and heart failure such as pregnancy-related heart disease, Takotsubo syndrome, and anthracycline-induced cardiotoxicity.

KEY POINTS

  · Cardiovascular diseases have sex-specific characteristics.. · Imaging strategies and interpretation of imaging results should be adjusted for women.. · Imaging helps in the improvement of the sex-specific management of cardiovascular disease..

Use of Race, Ethnicity, and National Origin in Studies Assessing Cardiovascular Risk in Women With a History of Hypertensive Disorders of Pregnancy

Women with a history of hyperBtensive disorders of pregnancy (HDP) are at particularly high risk for cardiovascular disease (CVD) and CVD-related death, and certain racial and ethnic subpopulations are disproportionately affected by these conditions. We examined the use of race, ethnicity, and national origin in observational studies assessing CVD morbidity and mortality in women with a history of HDP. A total of 124 studies, published between 1976 and 2021, were reviewed. We found that white women were heavily overrepresented, encompassing 53% of all participants with HDP. There was limited and heterogeneous reporting of race and ethnicity information across studies and only 27 studies reported including race and/or ethnicity variables in at least 1 statistical analysis. Only 2 studies mentioned the use of these variables as a strength; several others (k = 18) reported a lack of diversity among participants as a study limitation. Just over half of included articles (k = 68) reported at least 1 sociodemographic variable other than race and ethnicity (eg, marital status and income); however, none investigated how they might have worked synergistically or antagonistically with race and/or ethnicity to influence participants' risk of CVD. These findings highlight significant areas for improvement in cardiovascular obstetrics research, including the need for more robust and standardized methods for collecting, reporting, and using sociodemographic information. Future studies of CVD risk in women with a history of HDP should explicitly examine racial and ethnic differences and use an intersectional approach.

Cerebrovascular events during pregnancy and puerperium

Though cerebrovascular complications of pregnancy remain relatively rare, they represent a potentially devastating event that necessitates prompt identification and treatment. Eighteen percent of strokes occurring in young women are linked to pregnancy. They occur mostly in the third trimester or during the post-partum period. Their biggest risk factors are hypertension, preeclampsia/eclampsia and migraine. Cerebrovascular events occurring during this period may involve specific pathophysiological processes that include embolic phenomena or endothelial dysfunction, but can also have common etiologies that are simply favored by the context of pregnancy. Thus, posterior encephalopathy and vasoconstriction cerebral syndrome are relatively frequently involved in cerebrovascular complications of pregnancy. Other very specific causes like amniotic fluid embolism or postpartum cardiomyopathy can also be responsible for such events. The management of stroke during pregnancy must be multidisciplinary and include a neurovascular expertise. Some conditions can lead to a long-life follow-up and modify the management of a future pregnancy.

Hypertensive Disorders of Pregnancy and Risk of Cardiovascular Disease-Related Morbidity and Mortality: A Systematic Review and Meta-Analysis

INTRODUCTION

Several studies have demonstrated that there is a higher risk of cardiovascular disease (CVD) in women with a history of hypertensive disorders of pregnancy (HDP). However, effect sizes varied greatly between these studies, and a complete overview of the existing data in the literature is lacking. We aimed to evaluate the association between HDP and the risk of CVD-related morbidity and mortality.

METHODS

Systematic literature searches were conducted in several electronic databases from inception to July 2019. Exposure of interest was any type of HDP. Outcomes of interest included any CVD, CVD-related mortality, and hypertension.

RESULTS

Sixty-six cohort and 7 case-control studies involving >13 million women were included. The overall combined relative risks (RRs) for women with a history of HDP compared with the reference group were 1.80 (95% confidence interval [CI] 1.67-1.94) for any CVD, 1.66 (1.49-1.84) for coronary artery heart disease, 2.87 (2.14-3.85) for heart failure, 1.60 (1.29-2.00) for peripheral vascular disease, 1.72 (1.50-1.97) for stroke, 1.78 (1.58-2.00) for CVD-related mortality, and 3.16 (2.74-3.64) for hypertension. Significant heterogeneity was partially explained by all or part of the variables including type of exposure, follow-up time, geographic region, and sample source.

CONCLUSIONS

Women with a history of HDP are at an increased risk of future CVD-related morbidity and mortality. Our study highlights the importance of life-long monitoring of cardiovascular risk factors in women with a history of HDP.

Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications

BACKGROUND

Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD.

METHODS

We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI).

RESULTS

Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage.

CONCLUSIONS

Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.

The effect of parity on longitudinal maternal hemodynamics

BACKGROUND

Parous women have a lower risk for pregnancy complications, such as preeclampsia or delivery of small-for-gestational-age neonates. However, parous women are a heterogeneous group of patients because they contain a low-risk cohort with previously uncomplicated pregnancies and a high-risk cohort with previous pregnancies complicated by preeclampsia and/or small for gestational age. Previous studies examining the effect of parity on maternal hemodynamics, including cardiac output and peripheral vascular resistance, did not distinguish between parous women with and without a history of preeclampsia or small for gestational age and reported contradictory results.

OBJECTIVE

The objective of the study was to compare maternal hemodynamics in nulliparous women and in parous women with and without previous preeclampsia and/or small for gestational age.

STUDY DESIGN

This was a prospective, longitudinal study of maternal hemodynamics, assessed by a bioreactance method, measured at 11⁺⁰ to 13⁺⁶, 19⁺⁰ to 24⁺⁰, 30⁺⁰ to 34⁺⁰, and 35⁺⁰ to 37⁺⁰ weeks' gestation in 3 groups of women. Group 1 was composed of parous women without a history of preeclampsia and/or small for gestational age (n = 632), group 2 was composed of nulliparous women (n = 829), and group 3 was composed of parous women with a history of preeclampsia and/or small for gestational age (n = 113). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal characteristics, medical history, and development of preeclampsia or small for gestational age in the current pregnancy.

RESULTS

In groups 1 and 2, cardiac output increased with gestational age to a peak at 32 weeks and peripheral vascular resistance showed a reversed pattern with its nadir at 32 weeks; in group 1, compared with group 2, there was better cardiac adaptation, reflected in higher cardiac output and lower peripheral vascular resistance. In group 3 there was a hyperdynamic profile of higher cardiac output and lower peripheral vascular resistance at the first trimester followed by an earlier sharp decline of cardiac output and increase of peripheral vascular resistance from midgestation. The incidence of preeclampsia and small for gestational age was highest in group 3 and lowest in group 1.

CONCLUSION

There are parity-specific differences in maternal cardiac adaptation in pregnancy.

Racial Residential Segregation and Hypertensive Disorder of Pregnancy Among Women in Chicago: Analysis of Electronic Health Record Data

BACKGROUND

Racial residential segregation is associated with higher rates of chronic hypertension, as well as greater risk of preterm birth and low birthweight. However, few studies have examined associations between segregation and hypertensive disorder of pregnancy (HDP).

METHODS

Electronic health records from 4,748 singleton births among non-Hispanic black women at Prentice Women's Hospital in Chicago, IL (2009-2013) were geocoded to the census tract level. Residential segregation was measured using the Gi* statistic, a z-score measuring the extent to which each individual's neighborhood composition deviates from the composition of the larger surrounding area. Segregation was categorized as low (z < 0), medium (z = 0-1.96) or high (z > 1.96). We estimated cross-sectional associations of segregation with HDP using multilevel logistic regression models with census tract random intercepts. Models adjusted for neighborhood poverty and maternal characteristics. We also examined effect modification by neighborhood poverty.

RESULTS

Overall, 27.2% of women lived in high segregation, high-poverty neighborhoods. Racial residential segregation was not associated as a main effect with HDP in models adjusting for neighborhood poverty and maternal characteristics. However, at higher levels of neighborhood poverty (>20%), women living in high- and medium-segregated neighborhoods had greater odds of HDP relative to those in low-segregation neighborhoods (P interaction: 0.002).

CONCLUSIONS

In this sample of non-Hispanic black women in Chicago, racial residential segregation was associated with greater prevalence of HDP among those living in higher poverty neighborhoods. Understanding sources of heterogeneity in the relationship between segregation and health will help refine targeted intervention efforts to reduce disparities.

Associations of neighbourhood crime with adverse pregnancy outcomes among women in Chicago: analysis of electronic health records from 2009 to 2013

BACKGROUND

Adverse pregnancy outcomes are associated with higher cardiovascular disease risk among mothers and future health problems of offspring. Neighbourhood crime may contribute to adverse pregnancy outcomes by increasing chronic stress, yet the association has been relatively understudied.

METHODS

Electronic health records from 34 383 singleton births at a single hospital in Chicago (2009-2013) were geocoded and linked to 1-year rates of police-recorded crime at the neighbourhood (Chicago community area) level. Crimes included homicide, assault/battery, criminal offences and incivilities. Cross-sectional associations of total neighbourhood crime rates with hypertensive disease of pregnancy (HDP: pre-eclampsia/gestational hypertension), preterm birth (PTB), spontaneous preterm birth (sPTB) and small-for-gestational-age (SGA) birth were assessed using multilevel logistic regression with community-area random intercepts. Models controlled for maternal and infant characteristics and neighbourhood poverty. We then assessed associations between individual crime categories and all outcomes.

RESULTS

Total neighbourhood crime rates ranged from 11.6 to 303.5 incidents per 1000 persons per year (mean: 61.5, SD: 40.3). A 1-SD higher total neighbourhood crime rate was associated with higher odds of HDP (OR: 1.06, 95% CI 1.00 to 1.13), PTB (OR: 1.09, 95% CI 1.03 to 1.15), sPTB (OR: 1.09, 95% CI 1.03 to 1.16) and SGA (OR: 1.05, 95% CI 1.01 to 1.10) in fully adjusted models. Associations were generally consistent across crime categories, although only assault/battery and incivilities were associated with HDP.

CONCLUSIONS

Higher neighbourhood crime rates were associated with small but significant increases in the odds of adverse pregnancy outcomes. Interventions that cultivate safer neighbourhoods may be a promising approach for improving pregnancy outcomes.

The arteriolar injury in hypertension

In 1937, Drs. Moritz and Oldt described arteriolar injuries in the kidneys (and other viscera) in hypertension, across the age range, in both sexes, and, in different races. This hypothesis proposes that injuries to vasomotor nerves cause the arteriolar injury in the kidney in hypertension, (as well as that in the uterus in preeclampsia). Different patterns of perivascular hyalinisation in different viscera are clues to the varying causes and consequences of arteriolar injury. In the uterus there is a symmetrical, perivascular "halo of hyalinisation" that marks the lines of extension of regenerating, injured nerves to the placental bed, whereas in the kidney there is a disordered and asymmetrical "halo of hyalinisation" where persistent, and recurrent, increases in intravascular pressures interrupt development of regenerating nerves. Consequences of injuries to vasomotor nerves include releasing a "soup" of cytokines that cause regeneration of "new" nerves expressing primitive, pain and stretch receptors including TRPV-1 and P2X3 purinergic "stretch" receptors that may be significant in the afferent mechanism in preeclampsia. There is also concurrent, "background" hyperplasia of denervated tunica media and intima leading to narrowing of the arterioles and a further drive to hypertension through renal ischaemia (Goldblatt, 1942). These observations require support from animal studies and other investigations to establish causation. This hypothesis may provide a number of potential mechanisms that reinforce, or accelerate, the physiological processes that contribute to hypertension.

Lipid profile and cytokines in hypertension of pregnancy: A comparison of preeclampsia therapies

Hypertensive disorders complicating pregnancy can be classified as gestational hypertension, mild preeclampsia, and severe preeclampsia. It is necessary to evaluate and predict the grade in advance. The first study comprised 40 healthy pregnancies, 40 gestational hypertension, 40 mild preeclampsia, and 40 severe preeclampsia cases. The participants' lipid profile and cytokine levels were statistically compared. The efficacy and safety of oral nifedipine (n = 71) and intravenous labetalol (n = 72) for the treatment of severe preeclampsia were evaluated in the next study according to maternal and neonatal outcomes. The levels of lipid profile and cytokines were linked with the presence and severity of hypertensive disorders complicating pregnancy. Both oral nifedipine and intravenous labetalol are effective for safely reducing blood pressure to target levels in patients with severe preeclampsia. Our study suggests that lipid profile and cytokines can be used in the evaluation of the severity of hypertensive disorders complicating pregnancy, and oral nifedipine requires more study.

Invited Commentary: Gestational Hypertension and Diabetes-A Major Public Health Concern

The obesity epidemic in the United States and other countries has contributed to an increase in the rates of gestational diabetes and hypertension. In the past, it was thought that most cases of gestational diabetes and hypertension would resolve after completion of pregnancy. In this issue of the Journal, Pace et al. (Am J Epidemiol. 2017;186(10):1115-1124) clearly documented that both gestational diabetes and hypertension lead to diabetes and hypertension and that the combination of both during pregnancy leads to very high rates of subsequent diabetes and hypertension. A new generation of epidemiology studies using the evolving new technologies and genetics (host susceptibility studies) are needed to improve our understanding of the etiology of gestational diabetes and hypertension. Early identification of women at risk of gestational diabetes and hypertension, better treatment during pregnancy, and preventive and clinical therapies for treatment of diabetes and hypertension after pregnancy are very important for improving women's health and reducing risk of cardiovascular disease later in life.

Clinical Features and Outcomes of Acute Coronary Syndrome in Women With Previous Pregnancy Complications

BACKGROUND

Women with previous cardiometabolic complications of pregnancy experience double the risk of cardiovascular disease. However, few data exist on the clinical effect of these complications at the time of an acute coronary syndrome (ACS). The objective of this work was to compare risk factors, clinical features, and outcomes among women with premature ACS with or without previous pregnancy complications (gestational diabetes and/or hypertensive disorders of pregnancy).

METHODS

Data were obtained from a multicentre cohort of individuals hospitalized with premature ACS. A total of 251 parous women were included and provided obstetric history and blood samples. They were followed for the development of major adverse cardiac events at 12 months.

RESULTS

At presentation with ACS, women with a previous pregnancy complication (38%) were slightly younger than were women without such complications (47.4 ± 6.2 vs 49.1 ± 5.6 years; P = 0.002). They also had more traditional atherosclerotic risk factors. Specifically, women with previous preeclampsia were more likely to have chronic hypertension and an elevated ratio of soluble fms-like tyrosine kinase:placental growth factor. There was no between-group difference in Global Registry of Acute Coronary Events (GRACE) score or troponin tertile but there was a trend toward higher risk of ST-elevation myocardial infarction in women who had a previous pregnancy complication (odds ratio, 1.80; 95% confidence interval, 1.00-3.23; P = 0.05). There was also an increased risk of recurrent ACS at 12 months in women with previous preeclampsia (hazard ratio, 6.79; 95% confidence interval, 1.37-33.63; P = 0.02).

CONCLUSIONS

Among a cohort of women with ACS, previous pregnancy complications were associated with more severe disease and poorer outcome.

Young Women With Acute Myocardial Infarction: Current Perspectives

In recent years, there has been growing public awareness and increasing attention to young women with acute myocardial infarction (AMI), who represent an extreme phenotype. Young women presenting with AMI may develop coronary disease by different mechanisms and often have worse recoveries, with higher risk for morbidity and mortality compared with similarly aged men. The purpose of this cardiovascular perspective piece is to review recent studies of AMI in young women. More specifically, we emphasize differences in the epidemiology, diagnosis, and management of AMI in young women (when compared with men) across the continuum of care, including their pre-AMI, in-hospital, and post-AMI periods, and highlight gaps in knowledge and outcomes that can inform the next generation of research.