Impaired coronary microvascular function and increased intima-media thickness in preeclampsia

Usefulness of triglyceride-glucose index and homeostatic model assessment for predicting coronary microvascular dysfunction

BACKGROUND

Coronary microvascular dysfunction (CMD) is a common occurrence in individuals with insulin resistance (IR). Homeostatic model assessment for insulin resistance (HOMA-IR) is a widely used surrogate marker of IR, although recent studies suggest Triglyceride-Glucose (TyG) index is a superior marker of IR that had a better accuracy to predict Type 2 Diabetes or cardiovascular outcomes than HOMA-IR.

OBJECTIVES

We aimed to assess the accuracy and usefulness of TyG index and HOMA-IR for predicting CMD as assessed with echocardiographic coronary flow reserve (CFR) measurement.

METHODS

All cases included in the institutional CFR registry were retrospectively reviewed, and 656 cases without epicardial coronary artery disease and without major risk factors for atherosclerosis were included. A CFR ≤2.0 was defined as CMD.

RESULTS

TyG index was available in all cases, while HOMA-IR was available in 398 cases. Both TyG index and HOMA-IR were associated with CMD on univariate analyses, while after adjustment for potential confounders HOMA-IR (OR:1.38, 95 %CI:1.14-1.67, p = 0.001) but not TyG index(OR:1.48, 95 %CI:0.82-2.67, p = 0.19) was associated with CMD. The predictive accuracy of HOMA-IR (c-statistic:0.63, 95 %CI:0.54-0.72, p = 0.003) was higher than TyG index(c-statistic:0.55, 95 %CI:0.47-0.63, p = 0.13), although the difference was not statistically significant (DeLong p = 0.23). There was strong evidence favoring a true difference between CMD vs. non-CMD groups for HOMA-IR (BF10:3507) but not for TyG index(BF10:0.66).

CONCLUSIONS

HOMA-IR, but not TyG index, is closely associated with CMD.

Concomitant amyloidosis is the primary cause of endothelial and coronary microvascular dysfunction in carpal tunnel syndrome

Study objectives

Patients with carpal tunnel syndrome (CTS) show manifestations of arterial abnormalities, including carotid intimal thickening and increased vascular stiffness. As carpal tunnel syndrome is associated with amyloidosis, we hypothesized that previously observed abnormalities can largely be related with concomitant amyloidosis rather than CTS itself.

Design

Prospective observational study.

Setting

Medeniyet University Goztepe Hospital.

Participants

61 patients with CTS (of whom 32 had biopsy-proven amyloidosis) and 36 healthy controls.

Interventions

Subjects underwent ultrasound examinations for the measurement of coronary flow velocity reserve (CFVR), flow-mediated vasodilatation (FMD) and carotid intimal-media thickness (CIMT).

Main outcome measures

Comparison of CFVR, FMD and CIMT in CTS patients with or without amyloidosis.

Results

Patients with either CTS or CTS with concomitant amyloidosis (CTS-A) had significantly lower FMD (9.7 % ± 4.0 % in CTS and 10.3 % ± 4.6 % in CTS-A groups, p < 0.05 for both) and CFVR (2.4 (2.1-2.8) in CTS and 1.8 (1.6-2.1) in CTS-A groups, p < 0.001 for both) as compared to controls, while CIMT was only increased in CTS-A group (0.70 (0.60-0.80), p < 0.001). The reduction in CFVR was solely related to an increased basal flow velocity in CTS patients while there was also a reduced hyperemic flow velocity in patients with CTS-A.

Conclusion

Most arterial phenomena in CTS patients could be attributable to concomitant amyloidosis, although endothelial dysfunction was present even in patients with CTS without amyloidosis.

Gut microbiota-derived metabolite trimethylamine N-oxide and biomarkers of inflammation are linked to endothelial and coronary microvascular function in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD), which is an umbrella term used for ulcerative colitis (UC) and Crohn's disease (CD), is associated with an increased risk for atherosclerotic cardiovascular disease (CVD). We aimed to investigate the association of local and systemic biomarkers of inflammation and gut microbiota-derived metabolite trimethylamine N-oxide (TMAO) with endothelial and coronary microvascular dysfunction in IBD.

METHODS

A total of 56 patients with IBD (20 with UC and 36 with CD) and 34 age and gender matched controls were included. For all participants, samples were collected to analyze faecal calprotectin, and TMAO concentrations. Ultrasound-based examinations were done to measure flow-mediated vasodilatation (FMD) and coronary flow velocity reserve (CFVR).

RESULTS

Patients with IBD had lower CFVR (2.07 (1.82-2.40)) and FMD (8.7 ± 3.7) as compared to controls (2.30 (2.07-2.74), p = 0.005 and 11.9 ± 6.8, p = 0.03). In patients with IBD, TMAO concentration (r = -0.30, p = 0.03), C-reactive protein (r = -0.29, p = 0.03) and WBC count (r = -0.37, p = 0.006) had a significant negative correlation with CFVR, and TMAO (β = -0.27, 95 % CI: -0.23 to -0.02) and WBC count (β = -0.31, 95 % CI: -0.56 to -0.06) were significant predictors of CFVR after multivariate adjustment. None of the biomarkers of inflammation or TMAO showed significant correlations with FMD. In patients with UC, TMAO showed a significant correlation with both CFVR (r = -0.55, p = 0.01) and FMD (r = -0.60, p = 0.005) while only WBC count had a statistically significant correlation with CFVR (r = -0.49, p = 0.004) in patients with CD.

CONCLUSIONS

Gut microbiota-derived metabolite TMAO and biomarkers of systemic inflammation are associated with measures of endothelial/coronary microvascular dysfunction in patients with IBD.

Comparison of carotid intima media thickness between women with history of preeclampsia and normal pregnancy: a meta-analysis of systematic review

Background

On a clinical level, preeclampsia and atherosclerotic cardiovascular disease share common risk factors. Carotid intima media thickness (CIMT) is ultrasound-based imaging, non-invasive, simple, and reproducible method of subclinical atherosclerosis evaluation. Nowadays, there were studies concerning of CIMT among preeclamptic women, although the results were different.

Objective

To prove that CIMT among women with histories of preeclampsia was greater compared to normal pregnancy.

Methods

We conducted a meta-analysis of studies that reported CIMT, in women who had preeclampsia and had normal pregnancy. Studies were identified through three databases: PubMed, Google Scholar, and SAGE Journals with publication year of 2010–2020. Heterogeneity was assessed using the I2 statistic. Standardized mean difference was used as measured of effect size.

Results

Nine eligible studies were included in the meta-analysis. This meta-analysis consisted of 439 women with preeclampsia histories and 526 women with normal pregnancy histories. Women who had preeclampsia had significantly higher CIMT compared to those with normal pregnancy with standardized mean difference −0.38 and 95% confidence interval (CI) −0.68 to −0.07 (p=0.02).

Conclusion

CIMT was greater among women with histories of preeclampsia compared to normal pregnancy.

Trial registration

PROSPERO CRD42021228825

Sex differences in heart failure with preserved ejection fraction: From traditional risk factors to sex-specific risk factors

Heart failure with preserved ejection fraction has a higher prevalence in women versus men. There are several proposed mechanisms to explain this sex discrepancy including differences in cardiovascular adaptation to comorbidities and potential underlying etiologic mechanisms. In this review, we summarize sex differences in traditional risk factors, such as obesity, diabetes, hypertension, and coronary artery disease, which contribute to the development of heart failure with preserved ejection fraction in women. Furthermore, we explore female-specific risk factors, such as sex hormones, adverse pregnancy outcomes, and other reproductive factors, which may explain the predominance of heart failure with preserved ejection fraction in women. Beyond sex differences in risk factors, there are also significant sex differences in outcomes with women reporting lower quality of life but overall better survival versus men. Finally, while treatment options for patients with heart failure with preserved ejection fraction are still limited, sex differences have also been reported for the available therapies, with suggestion of preferential benefit of specific heart failure with preserved ejection fraction therapies in women. Further work is required to better understand sex differences in heart failure with preserved ejection fraction, including deeper understanding of pathophysiological mechanisms, derivation of more accurate risk stratification models, and increased representation of women in clinical trials.

Maternal Cardiovascular Function Following a Pregnancy Complicated by Preeclampsia

Preeclampsia is a hypertensive pregnancy complication with an unknown etiology and high maternal burden worldwide. Burgeoning research has linked preeclampsia to adverse maternal health outcomes remote from pregnancy; however, the intermediary mechanisms responsible for this association have not been sufficiently established. In the present narrative review, we summarize leading evidence of structural and functional cardiovascular changes associated with prior preeclampsia, and how these changes may be linked to future maternal disease. KEY POINTS: · Prior preeclampsia is associated with subclinical structural and functional vascular changes remote from pregnancy.. · Maternal cardiac adaptations to preeclampsia may have long-term implications on cardiovascular health.. · Clinicians have an opportunity to minimize maternal disease risk following preeclampsia..

Sex-Based Differences in Heart Failure: JACC Focus Seminar 7/7

Sex-based differences exist in risk, symptoms, and management of heart failure (HF). Women have a higher incidence of HF with preserved ejection fraction compared with men. This may be partially caused by the cardiovascular effects of estrogen and sex-specific risk factors (eg, adverse pregnancy outcomes, premature menopause). Key gaps exist in understanding of gender-based differences in HF, which is a distinctly different concept than sex-based differences. Although evidence-based therapies for HF are available, only limited data address sex-specific efficacy, and no data address gender-based efficacy. Persistent shortcomings in representation of women and gender minority participants in clinical trials limit an actionable database. A comprehensive roadmap to close the sex/gender-based gap in HF includes the following: 1) sex/gender-specific personalized prevention; 2) sex/gender-neutral implementation of evidence-based therapies; and 3) sex/gender-appropriate policy-level initiatives to spur research assessing sex/gender-specific causes of HF; enhance sex/gender-specific subgroup reporting; and promote community engagement of these important patient cohorts.

Coronary Microvascular Dysfunction is Common in Patients Hospitalized with COVID-19 Infection

Background and Aims

Microvascular disease is considered as one of the main drivers of morbidity and mortality in severe COVID‐19, and microvascular dysfunction has been demonstrated in the subcutaneous and sublingual tissues in COVID‐19 patients. The presence of coronary microvascular dysfunction (CMD) has also been hypothesized, but direct evidence demonstrating CMD in COVID‐19 patients is missing. In the present study, we aimed to investigate CMD in patients hospitalized with COVID‐19, and to understand whether there is a relationship between biomarkers of myocardial injury, myocardial strain and inflammation and CMD.

Methods

39 patients that were hospitalized with COVID‐19 and 40 control subjects were included to the present study. Biomarkers for myocardial injury, myocardial strain, inflammation, and fibrin turnover were obtained at admission. A comprehensive echocardiographic examination, including measurement of coronary flow velocity reserve (CFVR), was done after the patient was stabilized.

Results

Patients with COVID‐19 infection had a significantly lower hyperemic coronary flow velocity, resulting in a significantly lower CFVR (2.0 ± 0.3 vs. 2.4 ± 0.5, p < .001). Patients with severe COVID‐19 had a lower CFVR compared to those with moderate COVID‐19 (1.8 ± 0.2 vs. 2.2 ± 0.2, p < .001) driven by a trend toward higher basal flow velocity. CFVR correlated with troponin (p = .003, r: −.470), B‐type natriuretic peptide (p < .001, r: −.580), C‐reactive protein (p < .001, r: −.369), interleukin‐6 (p < .001, r: −.597), and d‐dimer (p < .001, r: −.561), with the three latter biomarkers having the highest areas‐under‐curve for predicting CMD.

Conclusions

Coronary microvascular dysfunction is common in patients with COVID‐19 and is related to the severity of the infection. CMD may also explain the “cryptic” myocardial injury seen in patients with severe COVID‐19 infection.

Maternal Vascular Lesions in the Placenta Predict Vascular Impairments a Decade After Delivery

Women with adverse pregnancy outcomes later experience excess hypertension and cardiovascular disease, but how the events are linked is unknown. Examination of the placenta may provide clues to vascular impairments after delivery. Maternal vascular malperfusion lesions (MVMs) were abstracted from clinical reports, validated and characterized using clinical guidelines and severity score. A total of 492 women (170 with MVMs and 322 without MVMs) participated in a study visit 8 to 10 years after delivery to assess blood pressure, cardiometabolic factors, and sublingual microvascular features using sidestream dark field imaging. Covariates included age, race, adverse pregnancy outcomes (preeclampsia, small for gestational age, and preterm birth), and health behaviors. Women with versus without MVM had a distinct sublingual microvascular profile comprised of (1) lower microvascular density (-410 μm/mm², P=0.015), (2) higher red blood cell filling as a marker of perfusion (2%, P=0.004), and (3) smaller perfused boundary region (-0.07 µm, P=0.025) as a measure of glycocalyx integrity, adjusted for covariates including adverse pregnancy outcomes. Women with MVM also had higher adjusted diastolic blood pressure (+2.6 mm Hg, P=0.021), total and LDL (low-density lipoprotein)-cholesterol (+11.2 mg/dL, P=0.016; +8.7 mg/dL, P=0.031). MVM associations with subsequent cardiovascular measures did not vary by type of adverse pregnancy outcome, except among women with preterm births where blood pressure was higher only among those with MVM. Results were similar when evaluated as MVM severity. A decade after delivery, women with placental vascular lesions had an adverse cardiovascular profile comprised of microvascular rarefaction, higher blood pressure and more atherogenic lipids. Placental histopathology may reveal a woman's early trajectory toward subsequent vascular disease.

Adverse Pregnancy Outcomes and Incident Heart Failure in the Women's Health Initiative

IMPORTANCE

Some prior evidence suggests that adverse pregnancy outcomes (APOs) may be associated with heart failure (HF). Identifying unique factors associated with the risk of HF and studying HF subtypes are important next steps.

OBJECTIVE

To investigate the association of APOs with incident HF overall and stratified by HF subtype (preserved vs reduced ejection fraction) among postmenopausal women in the Women's Health Initiative (WHI).

DESIGN, SETTING, AND PARTICIPANTS

In 2017, an APO history survey was administered in the WHI study, a large multiethnic cohort of postmenopausal women. The associations of 5 APOs (gestational diabetes, hypertensive disorders of pregnancy [HDP], low birth weight, high birth weight, and preterm delivery) with incident adjudicated HF were analyzed. In this cohort study, the association of each APO with HF was assessed using logistic regression models and with HF subtypes using multinomial regression, adjusting for age, sociodemographic characteristics, smoking, randomization status, reproductive history, and other APOs. Data analysis was performed from January 2020 to September 2021.

EXPOSURES

APOs (gestational diabetes, HDP, low birth weight, high birth weight, and preterm delivery).

MAIN OUTCOMES AND MEASURES

All confirmed cases of women hospitalized with HF and HF subtype were adjudicated by trained physicians using standardized methods.

RESULTS

Of 10 292 women (median [IQR] age, 60 [55-64] years), 3185 (31.0%) reported 1 or more APO and 336 (3.3%) had a diagnosis of HF. Women with a history of any APO had a higher prevalence of hypertension, diabetes, coronary heart disease, or smoking. Of the APOs studied, only HDP was significantly associated with HF with a fully adjusted odds ratio (OR) of 1.75 (95% CI, 1.22-2.50), and with HF with preserved ejection fraction in fully adjusted models (OR, 2.06; 95% CI, 1.29-3.27). In mediation analyses, hypertension explained 24% (95% CI, 12%-73%), coronary heart disease 23% (95% CI, 11%-68%), and body mass index 20% (95% CI, 10%-64%) of the association between HDP and HF.

CONCLUSIONS AND RELEVANCE

In this large cohort of postmenopausal women, HDP was independently associated with incident HF, particularly HF with preserved ejection fraction, and this association was mediated by subsequent hypertension, coronary heart disease, and obesity. These findings suggest that monitoring and modifying these factors early in women presenting with HDP may be associated with reduced long-term risk of HF.

Novel glycoproteins identify preclinical atherosclerosis among women with previous preeclampsia regardless of type 1 diabetes status

BACKGROUND AND AIMS

Information regarding inflammation and cardiovascular disease (CVD) risk in type 1 diabetes (T1D) or preeclampsia (PE) is scarce. We assessed differences in inflammation markers according to the presence of both conditions and their association with atherosclerosis.

METHODS AND RESULTS

We recruited 112 women without CVD and last pregnancy ≥5 years previously (n = 28 per group): a)T1D and PE; b)T1D without PE; c)PE without T1D; and d)Controls (without T1D or PE). Groups were matched by several CVD risk factors, and diabetes duration and retinopathy in T1D. Carotid intima-media thickness (IMT) and plaque presence (IMT ≥1.5 mm) were assessed by ultrasonography. Inflammatory markers included classical variables (leucocytes and high-sensitivity C-reactive protein [hsCRP]) and glycoproteins by nuclear magnetic resonance (¹H-NMR) spectroscopy (GlycA, GlycB, GlycF and the height/width [H/W] ratios of GlycA and GlycB). The age of the participants was 44.9 ± 7.8 years, and 20.5% harbored plaque. There were no differences in inflammatory markers among the four study groups. Overall, in multivariate-adjusted models, all ¹H-NMR-glycoproteins (except GlycB) were positively associated with IMT measures (IMT of bulb and maximum-IMT of any carotid segment; p < 0.05). After dividing the sample according to PE status, previous findings remained largely unchanged. Furthermore, GlycF was independently associated with carotid plaque only in PE group (OR 5.08 [1.03-25.01] per 0.1 log-increments, p = 0.046). Neither leucocytes nor hsCRP were related to atherosclerosis. Regarding T1D status, non-uniform results were observed.

CONCLUSIONS

High ¹H-NMR-glycoprotein concentrations have a negative impact on carotid atherosclerosis among women with preeclampsia, regardless of T1D status.

Maternal microvascular dysfunction during preeclamptic pregnancy

Preeclampsia is a hypertensive disorder of pregnancy effecting ∼5-8% of pregnancies in the United States, and ∼8 million pregnancies worldwide. Preeclampsia is clinically diagnosed after the 20th week of gestation and is characterized by new onset hypertension accompanied by proteinuria and/or thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. This broad definition emphasizes the heterogeneity of the clinical presentation of preeclampsia, but also underscores the role of the microvascular beds, specifically the renal, cerebral, and hepatic circulations, in the pathophysiology of the disease. While the diagnostic criteria for preeclampsia relies on the development of de novo hypertension and accompanying clinical symptoms after 20-week gestation, it is likely that subclinical dysfunction of the maternal microvascular beds occurs in parallel and may even precede the development of overt cardiovascular symptoms in these women. However, little is known about the physiology of the non-reproductive maternal microvascular beds during preeclampsia, and the mechanism(s) mediating microvascular dysfunction during preeclamptic pregnancy are largely unexplored in humans despite their integral role in the pathophysiology of the disease. Therefore, the purpose of this review is to provide a summary of the existing literature on maternal microvascular dysfunction during preeclamptic pregnancy by reviewing the functional evidence in humans, highlighting potential mechanisms, and providing recommendations for future work in this area.

The Fourth Trimester: Pregnancy as a Predictor of Cardiovascular Disease

Pregnancy identifies women who may be at a greater risk of cardiovascular disease (CVD), based on the development of adverse pregnancy outcomes (APOs), and may identify women who may benefit from atherosclerotic CVD (ASCVD) risk reduction efforts. APOs are common and although they are separate diagnoses, all these disorders seem to share an underlying pathogenesis. What is not clear is whether the APO itself initiates a pathway that results in CVD or whether the APO uncovers a woman's predisposition to CVD. Regardless, APOs have immediate risks to maternal and foetal health, in addition to longer-term CVD consequences. CVD risk assessment and stratification in women remains complex and, historically, has underestimated risk, especially in young women. Further research is needed into the role of ASCVD risk assessment and the effect of aggressive ASCVD risk modification on CVD outcomes in women with a history of APOs.

Combined past preeclampsia and gestational diabetes is associated with a very high frequency of coronary microvascular dysfunction

BACKGROUND

A history of preeclampsia (pPE) and gestational diabetes (pGDM) are female-specific risk markers for atherosclerosis and future cardiovascular risk. In addition to increasing the risk of established risk factors for atherosclerosis, such as hypertension or diabetes, evidence suggests that pregnancy-related complications can also directly accelerate atherosclerosis by inducing endothelial dysfunction. A combination of both conditions is seen in a subset of patients with pregnancy, though it is not known whether this combination increases the overall risk for cardiovascular events.

AIMS

Present study aimed to find the impact of combined pPE/pGDM on the prevalence of coronary microvascular dysfunction (CMD).

METHODS

A total of 24 patients with combined pPE/pGDM, 19 patients with isolated pPE and 63 patients with pGDM were included to the present study and a further 36 healthy women with no previous pregnancy-related complications served as controls. Coronary flow reserve was measured using echocardiography and CMD was defined as a coronary flow reserve ≤2.5.

RESULTS

Patients with combined pPE/pGDM had a high prevalence of CMD (91%), which was significantly higher than controls (5.6%, p < 0.001) and patients with pGDM (55%, p = 0.01). A history of pPE on top of pGDM was associated with an increased risk of CMD (HR:6.28, 95%CI:1.69-23.37, p = 0.006) after multivariate adjustment, but pGDM did not increase the odds for CMD in those with pPE.

CONCLUSIONS

Combined pPE/pDM is associated with a very high prevalence of CMD, which may indicate an increased risk for future cardiovascular events.

The pathogenic role of coronary microvascular dysfunction in the setting of other cardiac or systemic conditions

Coronary microvascular dysfunction (CMD) plays a pathogenic role in cardiac and systemic conditions other than microvascular angina. In this review, we provide an overview of the pathogenic role of CMD in the setting of diabetes mellitus, obesity, hypertensive pregnancy disorders, chronic inflammatory and autoimmune rheumatic disorders, chronic kidney disease, hypertrophic cardiomyopathy, and aortic valve stenosis. In these various conditions, CMD results from different structural, functional, and/or dynamic alterations in the coronary microcirculation associated with the primary disease process. CMD is often detectable very early in the course of the primary disease, before clinical symptoms or signs of myocardial ischaemia are present, and it portrays an increased risk for cardiovascular events.

Association between neutrophil to lymphocyte ratio and carotid artery wall thickness in healthy pregnant women

OBJECTIVE

Pregnancy may elicit a state of mild inflammation that might affect, either directly or indirectly, haematological parameters associated with systemic inflammation. In particular, both Neutrophil-to-lymphocyte ratio (NLR) and Red blood cells Distribution Width (RDW) have been found to be elevated in complicated pregnancy. However, data regarding the association of these haematological parameters with common carotid artery (CCA) intima-media thickness (IMT) in healthy pregnancy are scanty. Aim of this study was to evaluate possible changes in CCA-IMT during normal pregnancy and in the postpartum period, and to correlate these changes with NLR and RDW.

STUDY DESIGN

Between October 2019 and February 2020, a prospective study was carried out on 73 consecutive healthy pregnant women (32.8 ± 4.9 yrs/old). Women underwent obstetric assessment, complete blood cell counts with calculation of NLR and RDW, two-dimensional transthoracic echocardiography and carotid Doppler ultrasonography.

RESULTS

During normal pregnancy, both NLR and RDW progressively increased (p < 0.0001); likewise, parameters of carotid dimensions also significantly increased (p < 0.0001). Hematological and morphological changes all decreased in postpartum period. By univariable logistic regression, the variables which showed the greatest independent association with CCA-IMT (defined as CCA-IMT ≥0.55 mm) were: age (HR 1.33, 95% CI 1.15-1.53, p < 0.0001), pre-pregnant BMI (HR 2.75, 95% CI 1.72-4.41, p < 0.0001), third trimester E/e' ratio (HR 1.64, 95% CI 1.34-2.02, p < 0.0001), and third trimester NLR (HR 3.00, 95% CI 1.64-5.50, p < 0.0001). Multivariable logistic regression analysis demonstrated that third trimester NLR was the only variable that retained statistical significance (HR 2.49, 95% CI 1.35-4.59, p = 0.003). An NLR ≥ 2 reached 83% of sensitivity and 99% of specificity in identifying a CCA-IMT ≥0.55 mm (AUC = 0.95). A strong linear correlation of both third trimester NLR and RDW with CCA-IMT was observed (r = 0.89 and 0.83, respectively).

CONCLUSIONS

Pregnancy is a state of chronic mild inflammation and the progressive increase in NLR and RDW during normal pregnancy is significantly associated with CCA intimal-medial thickening.

Reduced coronary flow velocity reserve in women with previous pre-eclampsia: link to increased cardiovascular disease risk

OBJECTIVES

To evaluate differences in coronary microvascular function approximately 12 years after delivery between women who had had early- (EO-PE) or late- (LO-PE) onset pre-eclampsia and those who had had a normotensive pregnancy, and to assess the relationship between microvascular function and myocardial deformation at follow-up in these women.

METHODS

This was a case-control study of 88 women who had delivered at the Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark, between 1998 and 2008. Coronary flow velocity reserve (CFVR) was assessed by Doppler echocardiography approximately 12 years after delivery. Women were grouped according to whether the pregnancy had been complicated by EO-PE (n = 29) or LO-PE (n = 20), or had been normotensive (controls) (n = 39). Study groups were matched for maternal age and time since delivery. CFVR at follow-up was compared between the study groups. Regression analysis was used to assess the association between gestational age at onset of PE and CFVR. The association between left ventricular global longitudinal strain (LV-GLS) and CFVR at follow-up was also evaluated.

RESULTS

Resting coronary flow velocity assessed 12 years after delivery was comparable between the study groups (P = 0.55), whereas peak hyperemic flow velocity was significantly lower in the EO-PE group than in the LO-PE group (P < 0.01) and controls (P < 0.0001). As such, mean CFVR at follow-up was significantly lower in the EO-PE group than in the LO-PE group (P < 0.01) and controls (P < 0.0001). CFVR was < 2.5 in 48% of women in the EO-PE group, 25% of those in the LO-PE group and 8% of controls (P < 0.01). There was a significant positive association between gestational age at diagnosis of PE and CFVR at 12-year follow-up (β1 = 1.8 (95% CI, 0.8-2.9); P < 0.01). This relationship remained significant after adjustment for cardiovascular risk factors, namely mean arterial blood pressure, glycated hemoglobin level, body mass index, low-density lipoprotein cholesterol level and smoking status (P < 0.05). There was a significant association between LV-GLS and CFVR in women who had had PE (β1 = -1.5 (95% CI, -2.2 to -0.9); R²  = 0.33, P < 0.0001).

CONCLUSIONS

Low gestational age at onset of PE, both as a continuous variable and when categorized as early onset, was associated with decreased CFVR 12 years after delivery. Nearly 50% of women who had had EO-PE had CFVR < 2.5 at follow-up. Reduced CFVR in women who had had PE was associated with subclinical myocardial dysfunction in terms of reduced LV-GLS. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Preeclampsia Is Associated With Increased Preclinical Carotid Atherosclerosis in Women With Type 1 Diabetes

PURPOSE

Although preeclampsia (PE) is a well-established cardiovascular risk factor (CVRF) in the general population, its role in type 1 diabetes (T1D) has been scarcely studied. We assessed the association between PE and preclinical atherosclerosis in T1D.

METHODS

We recruited 112 women without cardiovascular disease and last pregnancy ≥5 years before: (1) T1D and previous PE (T1D+/PE+; n = 28); (2) T1D without preeclampsia (T1D+/PE-; n = 28); (3) previous PE without T1D (T1D-/PE+; n = 28); and (4) controls (without T1D or PE; T1D-/PE-; n = 28). Groups were matched by age, several CVRFs, and diabetes duration and retinopathy (in T1D participants). Carotid intima-media thickness (IMT) and the presence of plaque (IMT ≥ 1.5 mm) were assessed by standardized ultrasonography protocol.

RESULTS

Mean age of the participants was 44.9 ± 7.8 years (14.3% hypertension and 21.4% active smokers). Groups including T1D (T1D+/PE+ and T1D+/PE-) more frequently presented hypertension and statin treatment (23.2% vs 5.4% and 37.5% vs 8.9%; respectively; P < 0.01), without differences in other CVRFs. Carotid plaques were observed in 20.5%. In multivariate models adjusted for age, CVRF, and statins, both T1D and PE showed a similar impact on the presence of plaque, with odds ratios (95% confidence interval), 5.45 (1.36-21.9) and 4.24 (1.04-17.3), respectively. Both entities showed an additive effect when combined, both in common carotid-IMT (T1D+/PE- or T1D-/PE+, β = 0.198; T1D+/PE+, β = 0.297) and in the presence of plaque (8.53 [1.07-68.2] and 28.1 [2.67-296.4], respectively).

CONCLUSIONS

Previous PE was independently associated with preclinical atherosclerosis in T1D. Further studies are needed to ascertain its usefulness for stratifying risk in T1D women.

A Systematic Review of Vascular Structure and Function in Pre-eclampsia: Non-invasive Assessment and Mechanistic Links

Hypertensive disorders of pregnancy, such as pre-eclampsia, are known to be independently associated with the development of premature cardiovascular disease (CVD) in women. In pre-eclampsia, the placenta secretes excess anti-angiogenic factors into the maternal circulation, leading to widespread endothelial damage, and inflammation. This endothelial damage is evidenced to persist beyond the acute illness. However, whether it is permanent and responsible for the elevated rates of premature CVD seen in this at-risk group remains unclear. A systematic review of the available literature with respect to vascular structure and function prior to, during and after a pregnancy complicated by pre-eclampsia was performed. Studies non-invasively assessing vascular structure using carotid intima-media thickness (CIMT), retinal microvasculature caliber, CT coronary angiogram, or coronary calcium scores were included. Vascular function was assessed using brachial flow-mediated dilation (FMD), pulse wave analysis (PWA), and peripheral arterial tonometry (PAT). In total 59 articles were included (13 CIMT, 5 CTCA/Ca score, five retinal microvasculature, 27 FMD, 7 PAT, and 14 PWV/PWA), consisting of prospective and retrospective cohort, and case-control studies. Change in vascular structure was evidenced with significant increases in CIMT by 73-180 μm greater than that of non-affected women. This is tempered by other studies reporting resolution of structural changes postpartum, highlighting the need for further research. Accelerated coronary calcification and plaque deposition was identified, with greater rates of increased calcium scores and subclinical coronary artery disease shown by CTCA in women with a history of pre-eclampsia at 30 years postpartum. Impaired endothelial function was consistently reported prior to, during and immediately after pregnancy as evidenced by differences in FMD of 1.7-12.2% less than non-affected women, an increase in PWV by 13.2-26%, and reduced retinal microvascular caliber and arterial elasticity indices. The evidence was less conclusive for the persistence of long-term endothelial dysfunction. Understanding the underlying mechanistic links between pre-eclampsia and CVD is a key step to identifying targeted therapies aimed at "repairing the endothelium" and attenuating risk. This review has highlighted the need for a greater understanding of vascular structure and function following pre-eclampsia through high quality studies with large sample sizes, particularly in the longer postpartum period when clinical CVD disease starts to manifest.

A Systematic Review of Vascular Structure and Function in Pre-eclampsia: Non-invasive Assessment and Mechanistic Links

Hypertensive disorders of pregnancy, such as pre-eclampsia, are known to be independently associated with the development of premature cardiovascular disease (CVD) in women. In pre-eclampsia, the placenta secretes excess anti-angiogenic factors into the maternal circulation, leading to widespread endothelial damage, and inflammation. This endothelial damage is evidenced to persist beyond the acute illness. However, whether it is permanent and responsible for the elevated rates of premature CVD seen in this at-risk group remains unclear. A systematic review of the available literature with respect to vascular structure and function prior to, during and after a pregnancy complicated by pre-eclampsia was performed. Studies non-invasively assessing vascular structure using carotid intima-media thickness (CIMT), retinal microvasculature caliber, CT coronary angiogram, or coronary calcium scores were included. Vascular function was assessed using brachial flow-mediated dilation (FMD), pulse wave analysis (PWA), and peripheral arterial tonometry (PAT). In total 59 articles were included (13 CIMT, 5 CTCA/Ca score, five retinal microvasculature, 27 FMD, 7 PAT, and 14 PWV/PWA), consisting of prospective and retrospective cohort, and case-control studies. Change in vascular structure was evidenced with significant increases in CIMT by 73–180 μm greater than that of non-affected women. This is tempered by other studies reporting resolution of structural changes postpartum, highlighting the need for further research. Accelerated coronary calcification and plaque deposition was identified, with greater rates of increased calcium scores and subclinical coronary artery disease shown by CTCA in women with a history of pre-eclampsia at 30 years postpartum. Impaired endothelial function was consistently reported prior to, during and immediately after pregnancy as evidenced by differences in FMD of 1.7–12.2% less than non-affected women, an increase in PWV by 13.2–26%, and reduced retinal microvascular caliber and arterial elasticity indices. The evidence was less conclusive for the persistence of long-term endothelial dysfunction. Understanding the underlying mechanistic links between pre-eclampsia and CVD is a key step to identifying targeted therapies aimed at “repairing the endothelium” and attenuating risk. This review has highlighted the need for a greater understanding of vascular structure and function following pre-eclampsia through high quality studies with large sample sizes, particularly in the longer postpartum period when clinical CVD disease starts to manifest.

Early Pregnancy Cardiovascular Health and Subclinical Atherosclerosis

Background Assessing and optimizing cardiovascular health (CVH) early in life, such as in pregnancy, could lead to a longer lifetime spent in better CVH and reduce the risk of cardiovascular disease. This might especially benefit women with a hypertensive disorder of pregnancy (HDP) who are more likely to develop atherosclerosis and cardiovascular disease. We hypothesized that CVH in pregnancy is related to later life CVH and carotid intima-media thickness (CIMT), and that these associations differ between women with a normotensive pregnancy and women with an HDP. Methods and Results This study was conducted within the prospective population-based Generation R Study. CVH in pregnancy was based on 5 metrics (blood pressure, total-cholesterol, glucose, smoking, and body mass index). Postpartum CVH additionally included physical activity and diet scores, according to the American Heart Association classification. Postpartum CVH and CIMT were measured 10 years after pregnancy. Results were analyzed for women with a normotensive pregnancy and those with an HDP. Women with a normotensive pregnancy (n=1786) and women with an HDP (n=138) were evaluated from early pregnancy until 10 years postpartum. Better CVH in early pregnancy was associated with a smaller CIMT and better postpartum CVH in all women, especially in those with an HDP (CIMT: -9.82 μm [95% CI: -17.98, -1.67]). Conclusions Already in pregnancy, better CVH is associated with a smaller CIMT and better CVH 10 years postpartum, especially in women with an HDP. As pregnancy is an incentive for women to improve lifestyle, assessing CVH in pregnancy might help improve postpartum CVH and reduce cardiovascular disease risk.

Inflammation, depression and cardiovascular disease in women: the role of the immune system across critical reproductive events

Women are at increased risk for developing depression and cardiovascular disease (CVD) across the lifespan and their comorbidity is associated with adverse outcomes that contribute significantly to rates of morbidity and mortality in women worldwide. Immune-system activity has been implicated in the etiology of both depression and CVD, but it is unclear how inflammation contributes to sex differences in this comorbidity. This narrative review provides an updated synthesis of research examining the association of inflammation with depression and CVD, and their comorbidity in women. Recent research provides evidence of pro-inflammatory states and sex differences associated with alterations in the hypothalamic-pituitary-adrenal axis, the renin-angiotensin-aldosterone system and the serotonin/kynurenine pathway, that likely contribute to the development of depression and CVD. Changes to inflammatory cytokines in relation to reproductive periods of hormonal fluctuation (i.e. the menstrual cycle, perinatal period and menopause) are highlighted and provide a greater understanding of the unique vulnerability women experience in developing both depressed mood and adverse cardiovascular events. Inflammatory biomarkers hold substantial promise when combined with a patient's reproductive and mental health history to aid in the prediction, identification and treatment of the women most at risk for CVD and depression. However, more research is needed to improve our understanding of the mechanisms underlying inflammation in relation to their comorbidity, and how these findings can be translated to improve women's health.

Preeclampsia and coronary plaque erosion: Manifestations of endothelial dysfunction resulting in cardiovascular events in women

Atherosclerosis is the major underlying pathology of cardiovascular disease (CVD). The risk for CVD is increased in women with a history of preeclampsia. Multiple studies have indicated that accelerated atherosclerosis underlies this increased CVD risk. Furthermore, it has been suggested that endothelial dysfunction and inflammation play an important role in the increased CVD risk of women with preeclampsia. Rupture or erosion of atherosclerotic plaques can induce the formation of thrombi that underlie the onset of acute clinical CVD such as myocardial infarction and stroke. In relatively young women, cardiovascular events are mainly due to plaque erosions. Eroded plaques have a distinct morphology compared to ruptured plaques, but have been understudied as a substrate for CVD. The currently available evidence points towards lesions with features of stability such as high collagen content and smooth muscle cells and with distinct mechanisms that further promote the pro-thrombotic environment such as Toll Like Receptor (TLR) signaling and endothelial apoptosis. These suggested mechanisms, that point to endothelial dysfunction and intimal thickening, may also play a role in preeclampsia. Pregnancy is considered a stress test for the cardiovascular system with preeclampsia as an additional pathological substrate for earlier manifestation of vascular disease. This review provides a summary of the possible common mechanisms involved in preeclampsia and accelerated atherosclerosis in young females and highlights plaque erosion as a likely substrate for CVD events in women with a history of preeclampsia.

Coronary microvascular dysfunction is not associated with a history of reproductive risk factors in women with angina pectoris-An iPOWER substudy

BACKGROUND

Reproductive risk factors such as preeclampsia and recurrent miscarriages have been associated with adverse cardiovascular (CV) events. Underlying coronary microvascular dysfunction (CMD) may be a common denominator.

PURPOSE

We investigated whether a history of reproductive risk factors was associated with CMD in women with angina pectoris and no obstructive coronary artery disease (CAD).

METHODS

Participants from the iPOWER study, including women with angina pectoris and no obstructive CAD (<50% stenosis), were invited to complete an electronic survey regarding reproductive risk factors: recurrent miscarriages, gestational diabetes, preeclampsia, rhesus immunity, polycystic ovary syndrome and menopausal status as well as migraine and Raynaud phenomenon. CMD was assessed by transthoracic Doppler echocardiography with measurement of coronary flow velocity reserve (CFVR) during high-dose dipyridamole infusion, and analyzed in three categories with cut-off points at 2.0 and 2.5. Associations between CFVR and a history of reproductive risk factors were examined by age-adjusted trend test.

RESULTS

The questionnaire was completed by 613 women (73% of those invited), of whom 550 had a successful CFVR measurement. There was no significant difference in baseline characteristics between participants and non-participants. Median (interquartile range (IQR)) age was 62.8 (54.8; 68.7) years, median (IQR) BMI 26.2 (23.2; 29.8) kg/m², and 81.5% were postmenopausal. We did not find any significant associations between any of the reproductive risk factors, Raynaud's phenomenon or migraine and CFVR.

CONCLUSION

The lack of association between coronary microvascular function and a history of reproductive risk factors, migraine and Raynaud's phenomenon suggests that a common vascular pathophysiological mechanism underlying these conditions is unlikely.

Preclinical atherosclerosis at the time of pre-eclamptic pregnancy and up to 10 years postpartum: systematic review and meta-analysis

OBJECTIVES

Pre-eclampsia (PE) is a pregnancy-specific hypertensive disorder that has been associated with cardiovascular risk factors and vascular changes, such as acute atherosis in placental blood vessels, similar to early-stage atherosclerosis. The objective of this study was to determine whether women with PE have increased atherosclerotic burden, as determined by the carotid intima-media thickness (CIMT), compared with women without PE.

METHODS

We conducted a systematic review and meta-analysis of studies that reported CIMT, a non-invasive, ultrasound-based measure of subclinical atherosclerosis, in women who did vs those who did not have PE. Studies were eligible if they had been conducted during pregnancy or during the first decade postpartum, and if CIMT was measured in the common carotid artery. Studies published before 7 March 2016 were identified through PubMed, EMBASE and Web of Science. Two reviewers used predefined forms and protocols to evaluate independently the eligibility of studies based on titles and abstracts and to perform full-text screening, data abstraction and quality assessment. Heterogeneity was assessed using the I2 statistic. Standardized mean difference (SMD) was used as a measure of effect size.

RESULTS

Fourteen studies were included in the meta-analysis. Seven studies were carried out during pregnancy complicated by PE, 10 were carried out up to 10 years postpartum and three included measurements obtained at both time periods. Women who had PE had significantly higher CIMT than did those who did not have PE, both at the time of diagnosis (SMD, 1.10 (95% CI, 0.73-1.48); P < 0.001) and in the first decade postpartum (SMD, 0.58 (95% CI, 0.36-0.79); P < 0.001).

CONCLUSIONS

Atherosclerotic load is present at the time of PE and may be a mechanism associated with the disease. Measurement of CIMT may offer an opportunity for the early identification of premenopausal women with atherosclerotic burden after a PE pregnancy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Causes of changes in carotid intima-media thickness: a literature review

Atherosclerosis causes significant morbidity and mortality. Carotid intima-media thickness (CIMT) predicts future cardiovascular and ischaemic stroke incidence. CIMT, a measure of atherosclerotic disease, can be reliably determined in vivo by carotid ultrasound. In this review, we determined that CIMT is associated with traditional cardiovascular risk factors such as age, sex, race, smoking, alcohol consumption, habitual endurance exercise, blood pressure, dyslipidemia, dietary patterns, risk-lowering drug therapy, glycemia, hyperuricemia, obesity-related anthropometric parameters, obesity and obesity-related diseases. We also found that CIMT is associated with novel risk factors, including heredity, certain genotypic indices, anthropometric cardiovascular parameters, rheumatoid arthritis, immunological diseases, inflammatory cytokines, lipid peroxidation, anthropometric hemocyte parameters, infectious diseases, vitamin D, matrix metalloproteinases, and other novel factors and diseases. However, the conclusions are inconsonant; the underlying causes of these associations remain to be further explored.