Cardiovascular Consequences of Gestational Diabetes
2021; Lippincott Williams & Wilkins; Volume: 143; Issue: 10 Linguagem: Inglês
10.1161/circulationaha.120.052995
ISSN1524-4539
Autores Tópico(s)Cardiovascular Issues in Pregnancy
ResumoHomeCirculationVol. 143, No. 10Cardiovascular Consequences of Gestational Diabetes Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCardiovascular Consequences of Gestational Diabetes Jennifer B. Green, MD Jennifer B. GreenJennifer B. Green Jennifer B. Green, MD, Professor of Medicine, Division of Endocrinology, Department of Medicine, Duke Clinical Research Institute, 200 Morris St, PO Box 17969, Durham, NC 27715. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9967-5352 Division of Endocrinology, Department of Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC. Originally published8 Mar 2021https://doi.org/10.1161/CIRCULATIONAHA.120.052995Circulation. 2021;143:988–990This article is a commentary on the followingGestational Diabetes History and Glucose Tolerance After Pregnancy Associated With Coronary Artery Calcium in Women During MidlifeArticle, see p 1954Gestational diabetes (GD) complicates a substantial percentage of pregnancies worldwide, with ≈250 000 women affected annually in the United States alone.1,2 In addition to experiencing the direct risks to pregnancy outcomes posed by GD, women with a history of GD have an up to 7-fold increased risk of developing type 2 diabetes (T2D) later in life.3 Women with previous GD are also at increased risk of cardiovascular complications, with this increase in risk being detectable within 10 years postpartum.4,5 However, previously published analyses have not fully clarified whether this enhanced cardiovascular risk is attributable to the subsequent development of prediabetes or T2D, or to the presence of frequently concomitant cardiovascular risk factors such as obesity or dyslipidemia. A recent meta-analysis suggests that women with a history of GD have double the risk of major cardiovascular events compared with women without previous GD, irrespective of a T2D diagnosis later in life.5Results of the Gestational Diabetes History and Glucose Tolerance After Pregnancy Associated with Coronary Artery Calcium in Women During Mid-life study are published in this issue of Circulation.6 The authors have investigated the relationships between a history of GD, glucose tolerance later in reproductive life, and cardiovascular risk as defined by the presence of coronary artery calcium (CAC) in women enrolled in the CARDIA study (Coronary Artery Risk Development in Young Adults).7 CARDIA is a long-term, observational study assessing risk factors for coronary heart disease in a diverse group of >5000 men and women who were 18 to 30 years of age when recruited at multiple sites in the United States in the 1980s.7,8 The present analysis includes 1133 parous women without diabetes at baseline, for whom metabolic information was available before their first pregnancy and thereafter. Within this group, 139 women reported a pregnancy complicated by diagnosed GD. Assessment of CAC by computed tomography in all women occurred at years 15, 20, and 25 of study follow-up, and participants' corresponding glucose tolerance categories (normoglycemia, prediabetes, or incident diabetes) were identified. The authors hypothesized, and indeed have found, that a history of GD is associated with the presence of CAC even in women with subsequently normal glucose tolerance. In this group of women now at midlife, CAC was present in a significantly greater percentage of those with previous GD (24.5%) than without (15%). In women with prior GD, the risk of CAC score >0 was doubled in comparison with women without GD or T2D, and the proportion with CAC present did not vary across glucose tolerance categories. This contrasts with women without GD, in whom a graded increase in the risk of CAC was seen in those with later prediabetes and T2D. The increased risk of CAC in women with previous GD was found to be independent of numerous other clinical, lifestyle, and social determinants of cardiovascular risk, supporting a direct relationship between GD itself and the risk of future cardiovascular events. The validity of these findings is enhanced by the prospective nature of the CARDIA study, the large and diverse group of women enrolled, and the systematic collection of metabolic data and measurement of CAC during an extended period of follow-up. The ability to accurately categorize women as having normoglycemia, prediabetes, or T2D over time is a distinct strength of this study.Diabetes is particularly detrimental to cardiovascular health in women. In fact, the increase in relative risk of vascular disease associated with a T2D diagnosis is greater in women than in men and is considered independent of that conveyed by other traditional cardiovascular risk factors.9 This excess risk in women may be attributable, in part, to the greater amount of weight gain that women require to develop T2D or to the longer period women spend in the unfavorable metabolic stage of prediabetes than do men who progress to T2D.9,10 The findings from CARDIA support GD as another distinct diabetes-related hazard to cardiovascular health in women. This risk may be attributable to the effects of placental hormones or increased release of inflammatory cytokines during pregnancy that increase insulin resistance and may promote atherogenesis.4,5 However, some women may have a high-risk vascular phenotype that is present before pregnancy but which may only be first identified during routine screening for GD.5 The CARDIA findings do not allow us to make this distinction, nor can the impact of the degree of hyperglycemia, glycemic management strategies, or concomitant risk factors such as hypertension during pregnancy itself be ascertained. However, the CARDIA data do reinforce the suggested inclusion of GD as an emerging risk factor for ischemic coronary heart disease in women.11Considering the 50% to 60% lifetime risk of T2D posed by GD, current guidelines for the care of women with previous GD emphasize the need for regular screening for diabetes.12 Although this clearly is important, screening for diabetes alone may underestimate health risks in this group of women, and strategies to predict and more broadly address cardiovascular risk in women with previous GD are needed. In addition, interventions that reduce the risk of GD itself may be critically important if the associated cardiovascular risk later in life is not mitigated by achievement of normoglycemia. The role of preconceptual counseling may be key to reducing this longer-term risk, in particular, in women with a high cardiovascular risk phenotype that predates pregnancy. An emphasis on lifestyle changes intended to reduce the risk of GD may also have a favorable effect on nonglycemic cardiovascular risk factors, and, if sustained, could provide benefits beyond the postpartum period.Measurement of CAC in clinical practice may be useful in determining coronary atherosclerotic burden and stratifying cardiovascular risk in both men and women. In the present study of parous women, CAC scores were low, in general. In addition, CAC measurements were not performed before pregnancy; thus, it is possible that, in some women, the presence of CAC predated the development of GD. However, previous CARDIA analyses have found that the presence of any CAC in individuals aged 32 to 46 years was associated with a 3-fold increase in cardiovascular disease events and a 5-fold increase in the risk of coronary heart disease during a follow-up of up to 12.5 years.13,14 Because CAC is used as a surrogate for cardiovascular risk and complications in the present analysis, continued follow-up and correlation with actual cardiovascular events in this and other studies may more clearly demonstrate the independent risk posed by GD.Disclosures None.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circJennifer B. Green, MD, Professor of Medicine, Division of Endocrinology, Department of Medicine, Duke Clinical Research Institute, 200 Morris St, PO Box 17969, Durham, NC 27715. Email jennifer.[email protected]eduReferences1. Casagrande SS, Linder B, Cowie CC. 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Coronary Artery Risk Development in Young Adults Study (CARDIA).Accessed January 6, 2021 https://www.nhlbi.nih.gov/science/coronary-artery-risk-development-young-adults-study-cardiaGoogle Scholar9. Peters SAE, Woodward M. Sex differences in the burden and complications of diabetes.Curr Diab Rep. 2018; 18:33. doi: 10.1007/s11892-018-1005-5CrossrefMedlineGoogle Scholar10. Al-Salameh A, Chanson P, Bucher S, Ringa V, Becquemont L. Cardiovascular disease in type 2 diabetes: a review of sex-related differences in predisposition and prevention.Mayo Clin Proc. 2019; 94:287–308. doi: 10.1016/j.mayocp.2018.08.007CrossrefMedlineGoogle Scholar11. McSweeney JC, Rosenfeld AG, Abel WM, Braun LT, Burke LE, Daugherty SL, Fletcher GF, Gulati M, Mehta LS, Pettey Cet al; American Heart Association Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Hypertension, Council on Lifestyle and Cardiometabolic Health, and Council on Quality of Care and Outcomes Research. Preventing and experiencing ischemic heart disease as a woman: state of the science: a scientific statement from the American Heart Association.Circulation. 2016; 133:1302–1331. doi: 10.1161/CIR.0000000000000381LinkGoogle Scholar12. American Diabetes Association. 14. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes – 2021.Diabetes Care. 2021; 44suppl 1S200–S210. doi: 10.2337/dc21-S014CrossrefMedlineGoogle Scholar13. Okwuosa TM, Greenland P, Ning H, Liu K, Lloyd-Jones DM. Yield of screening for coronary artery calcium in early middle-age adults based on the 10-year Framingham Risk Score: the CARDIA study.JACC Cardiovasc Imaging. 2012; 5:923–930. doi: 10.1016/j.jcmg.2012.01.022CrossrefMedlineGoogle Scholar14. Carr JJ, Jacobs DR, Terry JG, Shay CM, Sidney S, Liu K, Schreiner PJ, Lewis CE, Shikany JM, Reis JPet al. Association of coronary artery calcium in adults aged 32 to 46 years with incident coronary heart disease and death.JAMA Cardiol. 2017; 2:391–399. doi: 10.1001/jamacardio.2016.5493CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesGestational Diabetes History and Glucose Tolerance After Pregnancy Associated With Coronary Artery Calcium in Women During MidlifeErica P. Gunderson, et al. Circulation. 2021;143:974-987 March 9, 2021Vol 143, Issue 10 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.052995PMID: 33683943 Originally publishedMarch 8, 2021 KeywordsEditorialsdiabetes, gestationaldiabetes mellitus, type 2heart disease risk factorsPDF download Advertisement
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