Prevalence of Subclinical Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography in 45- to 55-Year-Old Women With a History of Preeclampsia
2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 8 Linguagem: Inglês
10.1161/circulationaha.117.032695
ISSN1524-4539
AutoresGerbrand A. Zoet, Laura Benschop, Eric Boersma, Ricardo P.J. Budde, Bart C.J.M. Fauser, Yolanda van der Graaf, Christianne J.M. de Groot, Angela H.E.M. Maas, Jeanine E. Roeters van Lennep, Eric A.P. Steegers, Frank L.J. Visseren, Bas B. van Rijn, Birgitta K. Velthuis, Arie Franx, Yolande E. Appelman, Sara J. Baart, Laura Brouwers, Suzanne C. Cannegieter, Veerle Dam, Marianne Eijkemans, Michel D. Ferrari, Marlise N. Gunning, Annemieke Hoek, Hendrik Koffijberg, Maria P.H. Koster, Mark C. Kruit, Giske R. Lagerwij, Cornelis B. Lambalk, Joop S.E. Laven, Katie M. Linstra, Aad van der Lugt, Antoinette MaassenVanDenBrink, Cindy Meun, Saskia Middeldorp, Karel G.M. Moons, Jolien W. Roos‐Hesselink, Luuk J.J. Scheres, Régine P.M. Steegers‐Theunissen, Gisela M. Terwindt, Marieke J.H. Wermer,
Tópico(s)Cardiovascular Health and Disease Prevention
ResumoHomeCirculationVol. 137, No. 8Prevalence of Subclinical Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography in 45- to 55-Year-Old Women With a History of Preeclampsia Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessLetterPDF/EPUBPrevalence of Subclinical Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography in 45- to 55-Year-Old Women With a History of Preeclampsia Gerbrand A. Zoet, MD, PhD, Laura Benschop, MD, Eric Boersma, MD, PhD, Ricardo P.J. Budde, MD, PhD, Bart C.J.M. Fauser, MD, PhD, Yolanda van der Graaf, MD, PhD, Christianne J.M. de Groot, MD, PhD, Angela H.E.M. Maas, MD, PhD, Jeanine E. Roeters van Lennep, MD, PhD, Eric A.P. Steegers, MD, PhD, Frank L. Visseren, MD, PhD, Bas B. van Rijn, MD, PhD, Birgitta K. Velthuis, MD, PhD and Arie Franx, MD, PhDon behalf of the CREW Consortium Yolande E. Appelman, Sara J. Baart, Laura Brouwers, Suzanne C. Cannegieter, Veerle Dam, M.C.J. Eijkemans, Michel D. Ferrari, Marlise N. Gunning, Annemieke Hoek, Erik Koffijberg, M.P.H. Koster, Mark Kruit, Giske R. Lagerwij, C.B. Lambalk, Joop S. Laven, Katie Linstra, Aad van der Lugt, Antoinette Maassen van den Brink, Cindy Meun, Saskia Middeldorp, Karel G.M. Moons, Jolien W. Roos-Hesselink, Luuk J.J. Scheres, Regine P.M. Steegers-Theunissen, Gisela M. Terwindt and Marieke J.H. Wermer Gerbrand A. ZoetGerbrand A. Zoet Wilhelmina Children's Hospital Birth Center (G.A.Z., B.B.v.R., A.F.) , Laura BenschopLaura Benschop Department of Obstetrics and Gynaecology (L.B., E.A.P.S.) , Eric BoersmaEric Boersma Department of Cardiology (E.B., R.P.J.B.) , Ricardo P.J. BuddeRicardo P.J. Budde Department of Cardiology (E.B., R.P.J.B.) Department of Radiology (R.P.J.B.) , Bart C.J.M. FauserBart C.J.M. Fauser Department of Reproductive Medicine and Gynaecology (B.C.J.M.G.) , Yolanda van der GraafYolanda van der Graaf Julius Center for Health Sciences and Primary Care (Y.v.d.G.) , Christianne J.M. de GrootChristianne J.M. de Groot Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, Netherlands (G.J.M.d.G.) , Angela H.E.M. MaasAngela H.E.M. Maas Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands (A.H.E.M.M.) , Jeanine E. Roeters van LennepJeanine E. Roeters van Lennep Department of Internal Medicine (J.E.R.v.L.), Erasmus Medical Center, Rotterdam, Netherlands , Eric A.P. SteegersEric A.P. Steegers Department of Obstetrics and Gynaecology (L.B., E.A.P.S.) , Frank L. VisserenFrank L. Visseren Department of Vascular Medicine (F.L.V.) , Bas B. van RijnBas B. van Rijn Wilhelmina Children's Hospital Birth Center (G.A.Z., B.B.v.R., A.F.) Academic Unit of Human Development and Health, University of Southampton, Southampton, United Kingdom (B.B.v.R.). , Birgitta K. VelthuisBirgitta K. Velthuis Department of Radiology (B.K.V.), University Medical Center Utrecht, Netherlands and Arie FranxArie Franx Wilhelmina Children's Hospital Birth Center (G.A.Z., B.B.v.R., A.F.) Yolande E. AppelmanYolande E. Appelman , Sara J. BaartSara J. Baart , Laura BrouwersLaura Brouwers , Suzanne C. CannegieterSuzanne C. Cannegieter , Veerle DamVeerle Dam , M.C.J. EijkemansM.C.J. Eijkemans , Michel D. FerrariMichel D. Ferrari , Marlise N. GunningMarlise N. Gunning , Annemieke HoekAnnemieke Hoek , Erik KoffijbergErik Koffijberg , M.P.H. KosterM.P.H. Koster , Mark KruitMark Kruit , Giske R. LagerwijGiske R. Lagerwij , C.B. LambalkC.B. Lambalk , Joop S. LavenJoop S. Laven , Katie LinstraKatie Linstra , Aad van der LugtAad van der Lugt , Antoinette Maassen van den BrinkAntoinette Maassen van den Brink , Cindy MeunCindy Meun , Saskia MiddeldorpSaskia Middeldorp , Karel G.M. MoonsKarel G.M. Moons , Jolien W. Roos-HesselinkJolien W. Roos-Hesselink , Luuk J.J. ScheresLuuk J.J. Scheres , Regine P.M. Steegers-TheunissenRegine P.M. Steegers-Theunissen , Gisela M. TerwindtGisela M. Terwindt and Marieke J.H. WermerMarieke J.H. Wermer and on behalf of the CREW Consortium Originally published20 Feb 2018https://doi.org/10.1161/CIRCULATIONAHA.117.032695Circulation. 2018;137:877–879Preeclampsia is associated with an increased risk of coronary artery disease (CAD), although evidence on premature CAD development after preeclampsia is limited.1 A cross-sectional study among 491 postmenopausal women with a mean age of 67 years showed an increased prevalence of coronary artery calcification (CAC) in participants with self-reported high blood pressure during any previous pregnancy in comparison with women without such a history.2 However, the association between hypertensive pregnancy, CAC, and coronary plaque formation has not been reconfirmed in prospective studies, and there are no data on the timeline by which atherosclerosis develops in women with previous preeclampsia. The aim of this study is to compare the prevalence of coronary artery atherosclerosis of asymptomatic women aged 45 to 55 years who have a history of preeclampsia with a population-based reference cohort.The rationale and design of the CREW-IMAGO study (Cardiovascular Risk Profile: Imaging and Gender-Specific Disorders) have been published previously (URL: http://www.trialregister.nl/trialreg/index.asp. Unique identifier: NTR5531).3 Asymptomatic women, aged 45 to 55 years, with a history of preeclampsia 10 to 20 years earlier were included in this multicenter, prospective cohort study. Medical records, including pregnancy characteristics and hospital admission, were available for all women. Outcomes were compared with women of similar age and ethnicity who participated in the MESA study (Multi-Ethnic Study of Atherosclerosis).4 MESA is a prospective cohort study measuring CAC and traditional cardiovascular risk factors in 6814 multiethnic participants without a history of physician-diagnosed cardiovascular or neurovascular disease. For our analyses, MESA data were restricted to all participating women of white descent aged 45 to 55 years, resulting in a reference group of 387 women.Routine cardiovascular risk assessment included medical and pregnancy history, age, body mass index, waist circumference, blood pressure, and a venous blood sample assessing lipid profile, fasting plasma glucose, glycohemoglobin, and high-sensitivity C-reactive protein. CAC score (CACS) and contrast-enhanced coronary computed tomography angiography (CCTA) were performed in women with previous preeclampsia. In the MESA cohort only CACS was performed. CAC scores were converted to MESA percentiles adjusted for age, sex, and ethnicity. The primary outcome was the prevalence of CACS >0 Agatston units and any coronary atherosclerotic plaques on CCTA. Secondary outcomes included CACS ≥100 Agatston units, CACS ≥95th MESA percentile, and presence of a significant (≥50%) luminal stenosis on CCTA. The study was approved by the medical ethics committee of the University Medical Center Utrecht and all participants provided written informed consent. Analyses were performed with Statistical Package for Social Sciences (SPSS) version 22.0 (SPSS Inc).We included 164 asymptomatic women with a history of preeclampsia (mean age, 48.4±2.9 years at inclusion). Overall, 31% presented with a CACS >0 and 17% had CACS ≥95th MESA percentile. In comparison with the MESA reference group, women with a history of preeclampsia showed a higher risk of CACS >0 Agatston units (relative risk, 1.7; 95% confidence interval, 1.2–2.3), CACS >100 Agatston units (relative risk, 2.8; 95% confidence interval, 0.4–19.3), and CACS ≥95th MESA percentile (relative risk, 3.5; 95% confidence interval, 2.0–6.1). In addition, 47% of women with previous preeclampsia had coronary atherosclerotic plaques on CCTA and 4.3% showed significant stenosis. In comparison with the MESA cohort, women with a history of preeclampsia had a higher prevalence of hypertension and metabolic syndrome (Table).Table. Baseline Characteristics of the Preeclampsia Group and the Reference GroupPreeclampsiaMulti-Ethnic Study of Atherosclerosis (n=387)P ValueRelative Risk (95% CI)(n=164)(n=161)Patient characteristics Age, y48.4 (2.9)50.0 (3.0)<0.01 White ethnicity, n (%)162 (99)187 (100)0.09 History of pregnancy, n (%)164 (100)288 (75)<0.01 Premenopausal, n (%)78 (57)179 (46)<0.01Clinical measurements Systolic blood pressure, mm Hg130 (15)110 (16)<0.01 Diastolic blood pressure, mm Hg81 (10)66 (9)<0.01 Body mass index, kg/m228.1 (6.2)27.6 (6.7)0.40 Waist circumference, cm89.4 (13.3)92.8 (18.1)0.01 Total cholesterol, mmol/L5.4 (1.0)5.1 (1.0)<0.02 Triglycerides, mmol/L1.2 (0.5)1.4 (1.1)0.02 High-density lipoprotein cholesterol, mmol/L1.52 (0.34)1.49 (0.41)0.28 Low-density lipoprotein cholesterol, mmol/L3.4 (0.9)3.0 (0.8)<0.01 Glucose, mmol/L5.5 (1.1)4.7 (1.0)<0.01Cardiovascular disease risk factors Family history of premature cardiovascular disease, n (%)31 (19)114 (32)0.02 Hypertension,* n (%)89 (54)88 (23)<0.01 Diabetes mellitus, n (%)5 (3)10 (3)0.78 Current smoking, n (%)12 (8)69 (18)<0.01 Obesity, n (%)49 (30)114 (29)0.92 Metabolic syndrome,† n (%)54 (33)75 (20) 050 (31)70 (18)1.7 (1.2–2.3) 0.1–914 (9)33 (9)1.2 (0.6–2.1) 10–9926 (16)30 (8)2.2 (1.3–3.5) ≥10010 (6)7 (2)2.8 (0.4–19.3) Multi-Ethnic Study of Atherosclerosis≥95th percentile, n (%)28 (17)19 (5)3.5 (2.0–6.1)Coronary computed tomography angiography Any plaque, n (%)76 (47) Significant stenosis,‡ n (%)7 (4)Data are presented as mean±SD, unless otherwise stated. Unadjusted relative risk and 95% CIs presented.AU indicates Agatston units; and CI, confidence interval.*Blood pressure ≥140/90 mm Hg or current antihypertensive treatment.†According to the National Cholesterol Education Program Adult Treatment Panel III criteria.‡Luminal stenosis ≥50%.Our data are the first to demonstrate that preeclampsia is associated with accelerated atherosclerosis. CAC and plaques are detectable as early as the fifth decade of life, which may explain the higher rate of ischemic coronary events in these women as observed by Smith and colleagues in 2001.1 We present new evidence for signs of subclinical atherosclerosis on CCTA in middle-aged women with a history of preeclampsia in a well-phenotyped prospective cohort study. CCTA reference data on coronary plaques in the general population with similar ethnicity are not available yet. However, prevalence of subclinical plaques on CCTA has been reported in a retrospective cohort study from South Korea.5 The presence of plaques on CCTA in 1282 asymptomatic middle-aged women (50.0±8.4 years) was substantially lower than the plaque burden detected in our cohort of women with previous preeclampsia (6.7% versus 47.2%).Limitations of our study include uncertainty whether a positive CACS and CCTA result will progress to symptomatic CAD and ischemic coronary events, and the lack of data on women <45 years or of nonwhite ethnicity. Future research should address these knowledge gaps.In conclusion, 30% of women with a history of preeclampsia show signs of coronary atherosclerosis on vascular computed tomography imaging in comparison with 18% of women from the reference group. Therefore, women with previous preeclampsia have an increased risk of subclinical coronary artery atherosclerosis at age 45 to 55 years. These findings demonstrate that early coronary atherosclerosis precedes the development of subclinical ischemic heart disease in women with previous preeclampsia. Early identification of these women at high risk may facilitate timely prevention to reduce future CAD events.Gerbrand A. Zoet, MD, PhDLaura Benschop, MDEric Boersma, MD, PhDRicardo P.J. Budde, MD, PhDBart C.J.M. Fauser, MD, PhDYolanda van der Graaf, MD, PhDChristianne J.M. de Groot, MD, PhDAngela H.E.M. Maas, MD, PhDJeanine E. Roeters van Lennep, MD, PhDEric A.P. Steegers, MD, PhDFrank L. Visseren, MD, PhDBas B. van Rijn, MD, PhDBirgitta K. Velthuis, MD, PhDArie Franx, MD, PhDon behalf of the CREW ConsortiumSources of FundingThe CREw-IMAGO study is funded by the Dutch Heart Foundation (grant 2013T083). The Dutch Heart Foundation had no role in the collection, analysis, and interpretation of data, nor in the decision to submit the article for publication.DisclosuresNone.AppendixCollaborators of the CREW consortium: Yolande E. Appelman, Sara J. Baart, Laura Brouwers, Suzanne C. Cannegieter, Veerle Dam, M.C.J. Eijkemans, Michel D. Ferrari, Marlise N. Gunning, Annemieke Hoek, Erik Koffijberg, M.P.H. Koster, Mark Kruit, Giske R. Lagerwij, C.B. Lambalk, Joop S. Laven, Katie Linstra, Aad van der Lugt, Antoinette Maassen van den Brink, Cindy Meun, Saskia Middeldorp, Karel G.M. Moons, Jolien W. Roos-Hesselink, Luuk J.J. Scheres, Regine P.M. Steegers-Theunissen, Gisela M. Terwindt, Marieke J.H. WermerFootnoteshttp://circ.ahajournals.orgThe data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.117.032695/-/DC1.Gerbrand A. Zoet, MD, PhD, University Medical Center Utrecht, Room KE 02.510.2, Lundlaan 6, PO Box 85090, 3508 AB, Utrecht, the Netherlands. E-mail [email protected] or Arie Franx, MD, PhD, University Medical Center Utrecht, Rm KE 04.123.1, Lundlaan 6, PO Box 85090, 3508 AB, Utrecht, the Netherlands. E-mail [email protected]References1. Smith GC, Pell JP, Walsh DPregnancy complications and maternal risk of ischaemic heart disease: a retrospective cohort study of 129,290 births.Lancet. 2001; 357:2002–2006. doi: 10.1016/S0140-6736(00)05112-6.CrossrefMedlineGoogle Scholar2. 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