Small but clear increase more than 5 months post delivery
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Women with a history of hypertensive disorders of pregnancy, such as preeclampsia and gestational hypertension, had a small but significantly higher risk of developing cardiomyopathy more than 5 months after delivery versus women with normotensive pregnancies, according to a Danish study.
There was an increased risk of developing cardiomyopathy more than 5 years after their latest delivery among women who had gestational hypertension (HR 2.25, 95% CI 1.63-3.09), severe preeclampsia (HR 2.20, 95% CI 1.47-3.36), and moderate preeclampsia (HR 1.86, 95% CI 1.50-2.30), reported Ida Behrens, MD, of Statens Serum Institut in Copenhagen, and colleagues. These analyses were adjusted for maternal age, maternal birth year, parity, multiple pregnancy, and stillbirth.
Mediation analyses showed that approximately half of the observed association between hypertensive disorders of pregnancy and cardiomyopathy was associated with postgestational hypertension, with the remaining portion potentially attributable to hypertensive disorders of pregnancy, the authors wrote in the Journal of the American Medical Association.
However, the rate of cardiomyopathy among women with these pregnancy disorders was extremely low (16.3 per 100,000 person years for early preeclampsia and 14.6 per 100,000 person years for late preeclampsia), out of a cohort of 1,577 women with hypertensive disorders of pregnancy, the authors pointed out.
In an email to MedPage Today, Sarosh Rana, MD, of the University of Chicago, wrote that the findings were significant because "women who develop hypertension during pregnancy are at risk of heart failure, not only immediately following pregnancy but many years after delivery, which warrants appropriate follow-up."
"Further studies are needed to evaluate the role of pre-eclampsia in causing early and late cardiac dysfunction and treatments to modify this effect," wrote Rana, who was not involved in the study.
Women with preeclampsia already have an increased risk of idiopathic cardiomyopathy in the peripartum period. Behrens and colleagues noted that recent findings of persistent cardiac dysfunction and remodeling after preeclampsia suggest there may be an association between preeclampsia and an increased risk of cardiomyopathy outside the peripartum period.
The study cohort consisted of 1.07 million women with at least one pregnancy ending in live birth or still birth from 1978 to 2012 in Denmark's National Patient Register. Of those, 12,974 women had severe preeclampsia, 44,711 had moderate preeclampsia, and 18,423 had gestational hypertension.
Among the 1,577 women who developed cardiomyopathy during follow-up, 84 had moderate preeclampsia, 29 had gestational hypertension, 19 had severe preeclampsia, and 1,445 women had no hypertensive disorders of pregnancy during their first pregnancy.
Overall, 11% of all cardiomyopathy events in women who had previously given birth occurred among women with a history of hypertensive disorders of pregnancy. Not surprisingly, women with both early preterm preeclampsia and late preterm/term preeclampsia had an increased risk of cardiomyopathy events compared to women with no history of hypertensive disorders of pregnancy (HR 2.29 and 1.96, respectively).
The authors noted that the American Heart Association currently recommends monitoring for ischemic heart disease following preeclampsia, but that would likely not be the case for cardiomyopathy.
"A similar recommendation would not be justified for a more rare condition such as cardiomyopathy, regardless of the strength of the observed association with [hypertensive disorders of pregnancy]," they wrote.
There was no statistically significant difference in the results when stratified by age (<45 years versus >45 years). Adjusting for smoking, diabetes diagnosed during follow-up, and stopping follow-up due to the diagnosis of ischemic heart disease did not impact the associations.
While women with existing pregestational hypertension were excluded from the study, the authors noted the possibility of unrecognized pregestational hypertension and chronic hypertension subsequent to hypertensive disorders of pregnancy. Other potential study limitations included the fact that asymptomatic cardiomyopathy may be mistaken for other conditions with similar symptoms, such as asthma. Also, the authors were unable to adjust for BMI.
"Further research is necessary to understand whether there is a causal mechanism behind this association," they wrote.
There was an increased risk of developing cardiomyopathy more than 5 years after their latest delivery among women who had gestational hypertension (HR 2.25, 95% CI 1.63-3.09), severe preeclampsia (HR 2.20, 95% CI 1.47-3.36), and moderate preeclampsia (HR 1.86, 95% CI 1.50-2.30), reported Ida Behrens, MD, of Statens Serum Institut in Copenhagen, and colleagues. These analyses were adjusted for maternal age, maternal birth year, parity, multiple pregnancy, and stillbirth.
However, the rate of cardiomyopathy among women with these pregnancy disorders was extremely low (16.3 per 100,000 person years for early preeclampsia and 14.6 per 100,000 person years for late preeclampsia), out of a cohort of 1,577 women with hypertensive disorders of pregnancy, the authors pointed out.
In an email to MedPage Today, Sarosh Rana, MD, of the University of Chicago, wrote that the findings were significant because "women who develop hypertension during pregnancy are at risk of heart failure, not only immediately following pregnancy but many years after delivery, which warrants appropriate follow-up."
"Further studies are needed to evaluate the role of pre-eclampsia in causing early and late cardiac dysfunction and treatments to modify this effect," wrote Rana, who was not involved in the study.
Women with preeclampsia already have an increased risk of idiopathic cardiomyopathy in the peripartum period. Behrens and colleagues noted that recent findings of persistent cardiac dysfunction and remodeling after preeclampsia suggest there may be an association between preeclampsia and an increased risk of cardiomyopathy outside the peripartum period.
Among the 1,577 women who developed cardiomyopathy during follow-up, 84 had moderate preeclampsia, 29 had gestational hypertension, 19 had severe preeclampsia, and 1,445 women had no hypertensive disorders of pregnancy during their first pregnancy.
Overall, 11% of all cardiomyopathy events in women who had previously given birth occurred among women with a history of hypertensive disorders of pregnancy. Not surprisingly, women with both early preterm preeclampsia and late preterm/term preeclampsia had an increased risk of cardiomyopathy events compared to women with no history of hypertensive disorders of pregnancy (HR 2.29 and 1.96, respectively).
The authors noted that the American Heart Association currently recommends monitoring for ischemic heart disease following preeclampsia, but that would likely not be the case for cardiomyopathy.
"A similar recommendation would not be justified for a more rare condition such as cardiomyopathy, regardless of the strength of the observed association with [hypertensive disorders of pregnancy]," they wrote.
While women with existing pregestational hypertension were excluded from the study, the authors noted the possibility of unrecognized pregestational hypertension and chronic hypertension subsequent to hypertensive disorders of pregnancy. Other potential study limitations included the fact that asymptomatic cardiomyopathy may be mistaken for other conditions with similar symptoms, such as asthma. Also, the authors were unable to adjust for BMI.
"Further research is necessary to understand whether there is a causal mechanism behind this association," they wrote.
This study was funded by the Danish Heart Association and the Danish Council for Independent Research.
Behrens disclosed no relevant relationships with industry. Some co-authors disclosed relevant relationships with Novo Nordisk A/S, Global Development, Medical and Science, Søborg, Denmark, AstraZeneca, Sanofi, Shire, Pfizer, and Merck Sharp & Dohme.
Behrens disclosed no relevant relationships with industry. Some co-authors disclosed relevant relationships with Novo Nordisk A/S, Global Development, Medical and Science, Søborg, Denmark, AstraZeneca, Sanofi, Shire, Pfizer, and Merck Sharp & Dohme.
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