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Risk of MI After Pregnancy With Hypertension
Quick Takes
- Women with hypertensive disorders of pregnancy (HDP) have greater odds of having ACS in the future.
- Furthermore, pregnancy with HDP significantly increased the risk of a higher SYNTAX score, a marker of the degree of CAD.
- Women with HDP were also more likely to have MINOCA as compared to those with normotensive pregnancies.
Study Questions:
What is the anatomy of coronary arteries and the type of coronary artery lesions in women with a history of hypertensive disorders of pregnancy (HDP)?
Methods:
This study used a population-based cohort of parous female patients with incident coronary artery disease (CAD) who underwent coronary angiography and age-matched control subjects. The SYNTAX (Synergy between PCI [percutaneous coronary intervention] with TAXUS [Boston Scientific] and Cardiac Surgery) score was assessed to determine the complexity and degree of CAD; myocardial infarction with nonobstructive coronary arteries (MINOCA) was diagnosed in the presence of clinical acute myocardial infarction (MI) in the absence of obstructive coronary disease. Acute coronary syndrome (ACS) was defined as patients with MI or those with PCI or coronary artery bypass grafting with ST-segment elevation MI, non–ST-segment elevation MI, or unstable angina, on clinical chart review. Multivariable models were adjusted for the following risk factors for CAD unless otherwise specified: age, body mass index, smoking history, hyperlipidemia, diabetes, and hypertension.
Results:
A total of 506 parous female Olmsted County, Minnesota (USA) residents had incident CAD and angiographic data from November 7, 2002–December 31, 2016. Women with HDP were younger than normotensive women at the time of the event (median: 64.8 years vs. 71.8 years; p = 0.030). There was a strong association between HDP and ACS (unadjusted p = 0.018). In unadjusted models, the odds of overall HDP were significantly higher in ACS cases compared with control subjects (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.07-2.05; p = 0.018), and results remained significant after independent adjustment of covariates. Women with HDP compared with women with normotensive pregnancies were more likely to have a higher SYNTAX score (OR, 2.28; 95% CI, 1.02-5.12; p = 0.046) and MINOCA (OR, 2.08; 95% CI, 1.02-4.25; p = 0.044).
Conclusions:
The present study reports several novel findings regarding HDP and the future risk for CAD by using a population-based cohort. First, women with a history of HDP on average experience CAD events 7 years earlier than women with a history of normotensive pregnancies. Second, there is a strong association between HDP and ACS that remained significant after controlling for demographic variables and comorbidities. Third, among ACS cases, women with a history of HDP compared with women with normotensive pregnancies were more likely to have a higher atherosclerotic burden, as demonstrated by the SYNTAX score, and a diagnosis of MINOCA.
Perspective:
Given the substantial evidence, a history of HDP is included as a nontraditional, sex-specific cardiovascular disease (CVD) risk factor in recent guidelines. Such inclusion is important because the increased risk in women cannot be fully accounted for by the prevalence of traditional risk factors. Whether HDP facilitate subsequent CVD because of shared traditional risk factors and pathophysiological pathways or whether distinct mechanisms independent of conventional risk factors are playing a role is essentially unaddressed in the literature. These data demonstrate that nonatherosclerotic disease could play a significant role in the origin of ACS in 18% (i.e., one in five) of women with a history of HDP.
In this study, although most women with ACS and a history of HDP had clear evidence of MINOCA, one-third developed MI because of medical conditions leading to a mismatch in myocardial oxygen supply and demand, as in type 2 MI. Although the exact pathophysiology by which HDP promote ACS remains to be determined, recognition of a history of HDP as an independent risk factor for ACS, particularly MINOCA, may help stratify women who would benefit from risk reduction strategies and provide a novel therapeutic target for improving prognosis in women with ACS.
Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Vascular Medicine, Hypertension
Keywords: Cardio-Obstetrics, Hypertension, Pregnancy-Induced, Pregnancy, Myocardial Infarction
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