Cardiovascular disease risk factors in women with a history of early-onset preeclampsia.

OBJECTIVE: To assess the prevalence of established cardiovascular disease risk factors and to estimate 10-year absolute risk of cardiovascular disease after early-onset preeclampsia. METHODS: We assessed major cardiovascular disease risk factors in 243 primiparous women with a history of early-onset preeclampsia (delivery at less than 34 weeks of gestation) at least 6 months after delivery; 374 healthy nonpregnant women of similar age served as a reference group. RESULTS: After adjustment for age, we observed significantly higher means for body mass index, blood pressure, total and low-density lipoprotein cholesterol, triglycerides, glucose, and lower mean high-density lipoprotein cholesterol (all P<.01) in women with previous early-onset preeclampsia compared with the reference group. Prevalence of the metabolic syndrome was 15.2% compared with 4.3% (P<.001), two or more major cardiovascular disease risk factors were present in 51.0% compared with 26.5%, and three or more risk factors were present in 18.9% compared with 6.4%, respectively. Mean estimated 10-year cardiovascular disease risks by the Framingham Risk Score were 1.08% (95% confidence interval 1.04-1.12) and 1.01% (95% CI 1.00-1.01; P<.001) for the difference. CONCLUSION: Women with a history of early-onset preeclampsia have a high prevalence of several major cardiovascular disease risk factors. Although the estimated 10-year cardiovascular disease risk is low (less than 5%) after delivery, cardiovascular disease risk is expected to increase rapidly with increasing age. LEVEL OF EVIDENCE: II.

A model for preconceptional prediction of recurrent early-onset preeclampsia: derivation and internal validation.

OBJECTIVE: To develop a model to identify women at very low risk of recurrent early-onset preeclampsia. METHODS: We enrolled 407 women who had experienced early-onset preeclampsia in their first pregnancy, resulting in a delivery before 34 weeks' gestation. Preeclampsia was defined as hypertension (systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg) after 20 weeks' gestation with de novo proteinuria (≥300 mg urinary protein excretion/day). Based on the previous published evidence and expert opinion, 5 predictors (gestational age at previous birth, prior small-for-gestational-age newborn, fasting blood glucose, body mass index, and hypertension) were entered in a logistic regression model. Discrimination and calibration were evaluated after adjusting for overfitting by bootstrapping techniques. RESULTS: Early-onset disease recurred in 28 (6.9%) of 407 women. The area under the receiver operating characteristic (ROC) curve of the model was 0.65 (95% CI: 0.56-0.74). Calibration was good, indicated by a nonsignificant Hosmer-Lemeshow test (P = .11). Using a predicted absolute risk threshold of, for example, 4.6% (ie, women identified with an estimated risk either above or below 4.6%), the sensitivity was 100%, with a specificity of 26%. In such a strategy, no women who developed preeclampsia were missed, while 98 of the 407 women would be regarded as low risk of recurrent early-onset preeclampsia, not necessarily requiring intensified antenatal care. CONCLUSION: Our model may be helpful in the identification of women at very low risk of recurrent early-onset preeclampsia. Before widespread application, our model should be validated in other populations.

Prediction model for hypertension in pregnancy in nulliparous women using information obtained at the first antenatal visit.

OBJECTIVE: To develop a prediction model for the occurrence of hypertension in pregnancy using clinical variables obtained routinely at the antenatal booking visit prior to 16 weeks gestation. METHODS: We studied 2334 nulliparous pregnant women participating in two population-based prospective cohort studies. Potential predictors included maternal age, blood pressure, body weight, height, previous miscarriage and smoking history, assessed at the visit booking prior to 16 weeks gestation. The outcome measure was the development of hypertension before 36 weeks of gestation. A prediction model was derived from the regression model using discrimination, calibration, bootstrapping approaches and transformed into a prediction model usable in clinical practice. RESULTS: One hundred and forty-one of 2334 women (6.0%) developed hypertension. Main predictors were systolic and diastolic blood pressure, and weight. The area under the receiver operating characteristic curve of the model was 0.78, 95% confidence interval (CI) 0.75-0.82. Among women with a very low score (19% of the population) the risk of hypertension was 0.5%. In those with a high score (13% of the population) the risk was 22.9%. CONCLUSION: Among nulliparous and initially normotensive women, the use of three simple clinical variables obtained routinely at the antenatal booking visit prior to 16 weeks, can accurately identify women at very low and very high risk of becoming hypertensive before 36 weeks of gestation. When confirmed in recent cohorts, application of the prediction model may lead to a reduction in frequency of antenatal visits for low-risk and increased surveillance for high-risk women.

Cardiovascular risk factor assessment after pre-eclampsia in primary care.

BACKGROUND: Pre-eclampsia is associated with an increased risk of development of cardiovascular disease later in life. It is not known how general practitioners in the Netherlands care for these women after delivery with respect to cardiovascular risk factor management. METHODS: Review of medical records of 1196 women in four primary health care centres, who were registered from January 2000 until July 2007 with an International Classification of Primary Care (ICPC) code indicating pregnancy. Records were searched for indicators of pre-eclampsia. Of those who experienced pre-eclampsia and of a random sample of 150 women who did not, the following information on cardiovascular risk factor management after pregnancy was extracted from the records: frequency and timing of blood pressure, cholesterol and glucose measurements--and vascular diagnoses. Additionally the sensitivity and specificity of ICPC coding for pre-eclampsia were determined. RESULTS: 35 women experienced pre-eclampsia. Blood pressure was more often checked after pregnancy in these women than in controls (57.1% vs. 12.0%, p<0.001). In 50% of the cases blood pressure was measured within 3 months after delivery with no further follow-up visit. A check for glucose and cholesterol levels was rare, and equally frequent in PE and control women. 20% of the previously normotensive women in the PE group had hypertension at one or more occasions after three months post partum versus none in the control group. The ICPC coding for pre-eclampsia showed a sensitivity of 51.4% and a specificity of 100.0%. CONCLUSION: Despite the evidence of increased risk of future cardiovascular disease in women with a history of pre-eclampsia, follow-up of these women is insufficient and undeveloped in primary care in the Netherlands.

The angiotensinogen gene M235T polymorphism and development of preeclampsia/eclampsia: a meta-analysis and meta-regression of observational studies.

OBJECTIVE: The angiotensinogen gene M235T polymorphism is related to an increased risk of hypertension. Hypertension and pregnancy-induced hypertension have been suggested to share common etiologic factors. We examined whether this mutation also increases the risk of preeclampsia/eclampsia. METHODS: Pubmed/Medline, Web of Science and EMBASE were searched and a hand search of bibliographies was conducted. In all, 17 studies (including 1446 cases and 3829 controls) published in English between 1993 and October 2006 on the association of angiotensinogen gene M235T polymorphism with preeclampsia/eclampsia were selected. RESULTS: The overall odds ratio (OR) under a random effects model revealed that individuals homozygous for the T allele were 1.62 times more likely to develop preeclampsia/eclampsia [95% confidence interval (CI), 1.12 to 2.33; P = 0.01) compared to individuals homozygous for the M allele. The relation in Caucasians (OR = 1.99; 95% CI, 1.18-3.36; P = 0.01) was similar to that in East Asian populations (OR = 1.74; 95% CI, 0.92-3.28; P = 0.09), although the latter was not statistically significant due to lower numbers of studies. Under additive, recessive and dominant genetic models positive associations were also found. A meta-regression analysis showed that ethnic background was a significant source of between-study heterogeneity (P = 0.04) but design of the study, study size and Hardy-Weinberg equilibrium deviation were not. There was a low probability of publication bias. CONCLUSION: Our meta-analysis expands the findings on hypertension by showing that the presence of the T allele of the angiotensinogen gene is associated with an increased risk to develop preeclampsia/eclampsia.

Pulse pressure amplification and risk of cardiovascular disease.

BACKGROUND: Whether pulse pressure amplification (PPA) relates to established markers of cardiovascular risk is unknown. The purpose of this study was to investigate the relationship between PPA and cardiovascular risk factors and cardiovascular risk in a population-based sample of 40- to 80-year old men. METHODS: A cross-sectional, single-center study was performed in 400 men aged 40-80 years. PPA was calculated as a ratio (brachial pulse pressure/central pulse pressure). Detailed information on vascular risk factors was obtained. Aortic pulse wave velocity (PWV) and common carotid intima-media thickness (CIMT), as markers of vascular risk, were measured. We calculated the absolute 10-year risk of coronary heart disease using the Framingham risk score. Regression analysis was used to evaluate the relations under study. RESULTS: In models adjusted for age, mean arterial pressure (MAP), heart rate, and height, significant inverse relations with PPA were found for waist-to-hip ratio, triglycerides, smoking, pack-years, and hypertension. Furthermore, an increased PPA was significantly inversely related to aortic PWV, common CIMT, and history of symptomatic vascular disease. Finally, the Framingham risk score decreased with increasing PPA. CONCLUSION: Our study shows that a higher PPA reflects a lower vascular risk in men between 40 and 80 years of age, as shown by a better cardiovascular risk profile, a reduced PWV, common CIMT, and a lower Framingham risk of coronary heart disease.

Spurious systolic hypertension in young adults; prevalence of high brachial systolic blood pressure and low central pressure and its determinants.

OBJECTIVE: To investigate the prevalence and determinants of spurious systolic hypertension (SSH) in a population-based sample of young adults and estimate their 20-year risk of coronary heart disease. POPULATION AND METHODS: Seven hundred and fifty young adults (352 men and 398 women), aged 26-31 years, from the Atherosclerosis Risk in Young Adults study were studied. Blood pressure levels were measured twice and central (aortic) pressures were derived by applanation tonometry on the radial artery using a generalized transfer function. SSH was defined as brachial systolic blood pressure (SBP) > or = 140 mmHg, brachial diastolic blood pressure (DBP) < 90 mmHg, and central SBP < 124 mmHg for men and < 120 mmHg for women. The Framingham risk score was calculated. Analysis of variance models were used to compare SSH individuals with normotensive and hypertensive males for cardiovascular risk factors. RESULTS: SSH was diagnosed in 57 men (16.1%; 95% confidence interval, 12.3-20.0) versus only three women (8%; 95% confidence interval, 0-1.6). The female population was excluded from further analysis. Compared with normotensive males, SSH individuals were heavier (88.7 versus 81.8 kg, P < 0.05) had a higher body mass index (25.8 versus 24.2 kg/m, P < 0.01) and significantly higher brachial and central SBP, DBP, pulse pressure, and mean arterial pressure. They had significantly higher pulse pressure amplification. Twenty-year Framingham risk scores based on DBP did not differ significantly between SSH subjects and normotensive individuals (2.72 versus 2.10%, respectively). CONCLUSION: SSH is predominantly found among young adult men. Apart from weight and body mass index, no other cardiovascular risk factors differed significantly between subjects with SSH and normotension or hypertension. When calculating the 20-year risk of coronary heart disease based on brachial DBP, SSH individuals were at intermediate risk between normotensive and hypertensive participants, but differences were not statistically significant.