Tara Haelle

February 02, 2017

LAS VEGAS — Cardiac dysfunction exists at the time of pre-eclampsia and persists postpartum, potentially offering insights into the long-term cardiovascular risk that increases a decade later, according to three studies presented here at the Society for Maternal-Fetal Medicine 2017 Pregnancy Meeting.

"Whether pre-eclampsia unmasks underlying vascular disease or actually causes it is unknown," said Lisa Devine, MD, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. However, identifying early cardiac changes can help identify high-risk women, which can lead to early intervention, she pointed out.

In their prospective longitudinal cohort study, Dr Devine and her colleagues examined markers of cardiac function. All study participants were at 23 to almost 37 weeks of gestation with a singleton pregnancy and had undergone baseline pulsed-wave Doppler transthoracic echocardiography at the Hospital of the University of Pennsylvania. The final analysis involved 21 women with severe preterm pre-eclampsia and a control group of 16 women matched for gestational age, race, maternal age, and body mass index.

At baseline, ejection fraction was not statistically different between the pre-eclampsia and control groups; however, for longitudinal strain, the absolute value was lower in the pre-eclampsia group than in the control group, which indicates more abnormal function (12.6 vs 14.6; P < .04).

Table 1. Echocardiographic Markers of Diastolic Function

Marker Pre-eclampsia Group Control Group P Value
Peak early diastolic mitral annulus velocity 10.3 12.3 .05
Arterial load      
   Vascular stiffness 2.0 1.8 .04
   Ventricular stiffness 2.4 1.7 .006

 

The E/A ratio, which indicates function of the left ventricle, was lower in the pre-eclampsia group than in the control group, although not significantly.

Six weeks later, the absolute value of longitudinal strain was significantly lower in the pre-eclampsia group than in the control group (13.6 vs 15.6), and peak early diastolic mitral annulus velocity was lower in the pre-eclampsia group (10.3 vs 12.5). Arterial load remained higher in the pre-eclampsia group, but the difference was only marginally significant.

The effect of early-onset pre-eclampsia in women in their 50s was addressed in two studies presented by Anouk Bokslag, MD, who is a PhD student at VU University Medical Center in Amsterdam.

These women "are currently outside the scope of most preventive programs because of their relatively young age, but they have important modifiable risk factors for cardiovascular diseases," she explained.

Dr Bokslag and her colleagues looked at women who gave birth from 1998 to 2005, whose children were 9 to 16 years of age at the time of the study. The final analysis involved 131 women with a diagnosis of pre-eclampsia who gave birth before 34 weeks of gestation and a control group of 56 women who were normotensive, had uncomplicated pregnancies, and gave birth at 37 weeks of gestation or more, matched for year of delivery and maternal age.

Overall and low-density-lipoprotein cholesterol were not significantly different between the pre-eclampsia and control groups, but high-density-lipoprotein cholesterol was significantly lower in the pre-eclampsia group (P < .001), and triglyceride levels were lower (P < .005).

Table 2. Characteristics of the Study Participants

Characteristic Pre-eclampsia Group Control Group
Body mass index (m/kg²) 25.6 23.9
Waist circumference (cm) 79.0 77.0
High-density-lipoprotein cholesterol (mmol/L) 1.53 1.78
Triglycerides (mmol/L) 1.0 0.8
Average blood pressure    
   Systolic (mm Hg) 126.0 114.0
   Diastolic (mm Hg) 82.0 74.0
   Arterial (mm Hg) 96.7 87.4

 

"In women with a history of early-onset pre-eclampsia, 42% had major cardiovascular risk factors in the fifth decade of life," Dr Bokslag reported. "Specifically, 38% of the them had hypertension and almost 17% had metabolic syndrome." In contrast, 14% of the control group had a major cardiovascular risk factor, 14% had hypertension, and nearly 2% had metabolic syndrome.

In their second study of the same population, Dr Bokslag's team looked at pulsed-wave Doppler markers of diastolic dysfunction.

Peak diastolic mitral annulus velocity was higher in the pre-eclampsia group than in the control group, which indicates diastolic dysfunction in the women with a history of early-onset pre-eclampsia (65.36 vs 59.85 cm/s; P < .026).

Even after adjustment for body mass index, age, smoking, and systolic blood pressure, early-onset pre-eclampsia had a significant influence on diastolic dysfunction, Dr Bokslag told Medscape Medical News. She recommends that physicians explain to "patients who have early-onset pre-eclampsia, in pregnancy or shortly after, that they have an increased risk of developing cardiovascular disease."

In fact, she noted, "we can use the pregnancy as an early identification of women at risk."

However, current research is not far enough along to recommend changes to clinical guidelines, she pointed out.

"Intervention studies to investigate whether the reduction of cardiovascular risk factors will actually reduce cardiovascular disease, including diastolic dysfunction, in these women need to be been done before guidelines can be changed," Dr Bokslag explained.

"It seems apparent that things that happen during pregnancy can provide insight and potentially predict issues that happen in long-term health," said Bill Goodnight, MD, associate professor of maternal–fetal medicine at the University of North Carolina at Chapel Hill, who attended the session.

"Primary care providers should understand more about things that happen in pregnancy; they could be used as an additional risk factor in screening for heart disease and hypertension later on," he told Medscape Medical News. However, there is often "a disconnect between obstetricians and women's primary care providers," he pointed out.

"It's probably not that pre-eclampsia starts this process, but that pre-eclampsia is the expression of the disease in pregnancy that is a marker for that person being at risk for disease later on," Dr Goodnight explained.

"The theory is that whatever the underlying metabolic derangement is, it was there anyway, and that person may have been destined to have hypertension or stroke at age 50," he said.

Dr Devine, Dr Bokslag, and Dr Goodnight have disclosed no relevant financial relationships.

Society for Maternal-Fetal Medicine (SMFM) 2017 Annual Pregnancy Meeting. Presented January 27, 2017.

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