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Gestational diabetes doubles risk for CVD
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Women diagnosed with gestational diabetes are twice as likely to experience a cardiovascular event postpartum compared with women with normoglycemia during pregnancy, with the greatest risk observed in the first decade after giving birth, according to findings from a meta-analysis published in Diabetologia.
“Women with gestational diabetes are at increased risk for CVD whether or not they develop subsequent type 2 diabetes in the interim,” Ravi Retnakaran, MD, MSc, FRCPC, professor of medicine at the University of Toronto and an endocrinologist at the Leadership Sinai Centre for Diabetes at Mount Sinai Hospital in Toronto, told Endocrine Today. “Thus, the diagnosis of gestational diabetes should be recognized as enabling early identification of an at-risk patient population and, hence, an opportunity for early risk factor modification and possibly prevention of the leading cause of mortality in women.”
In a systematic review and meta-analysis, Retnakaran and colleagues analyzed data from nine studies published between 2013 and 2018 assessing 5,390,591 women with and without gestational diabetes, with mean follow-up ranging from 1 to 25.7 years. Researchers calculated overall RR to assess the predictive value of gestational diabetes for future CV events.
To evaluate the potential confounder effect of incident type 2 diabetes, researchers used random-effects meta-regression models to assess whether incident rates of type 2 diabetes among women with gestational diabetes influenced the association between gestational diabetes and CVD, and performed sensitivity analyses restricted to women who did not develop gestational diabetes.
Compared with women without a history of gestational diabetes, the RR for future CV events for women with previous gestational diabetes was 1.98 (95% CI, 1.57-2.5). In sensitivity analyses restricted to the three largest studies (n = 4,101,133 women), risk for future CV events persisted in women with previous gestational diabetes vs. those without gestational diabetes (RR = 1.52; 95% CI, 1.48-1.56).
In analyses assessing the potential impact of incident type 2 diabetes on CV risk in women with previous gestational diabetes, women who did not go on to develop type 2 diabetes still had a 56% higher risk for experiencing a CV event when compared with women who did not have a previous gestational diabetes diagnosis (RR = 1.56; 95% CI, 1.04-2.32).
In meta-regression analyses, researchers found that the differential risk for CVD between women with and without a gestational diabetes diagnosis was highest in the first decade after the index pregnancy and decreased over time (P = .06). In sensitivity analyses restricted to studies with a follow-up duration of less than 10 years, a gestational diabetes diagnosis was associated with a 2.3-fold increase in CV events in the first decade postpartum (RR = 2.31; 95% CI, 1.57-3.39).
“Future research should focus on the determinants of CV risk in women who have gestational diabetes, since these data show that type 2 diabetes alone does not account for their CV risk, and then intervention to modify these determinants,” Retnakaran said. – by Regina Schaffer
For more information:
Ravi Retnakaran, MD, MSc, FRCPC, can be reached at the Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, 60 Murray St., Suite L5-025, Mailbox-21, Toronto, Canada; email: ravi.retnakaran@sinaihealthsystem.ca.
Disclosures: Retnakaran reports he has received grants and personal fees from Boehringer Ingelheim, Eli Lilly, Merck, Novo Nordisk, Sanofi and Takeda. Another author reports she has received grants from Boehringer Ingelheim.
Perspective
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Margo B. Minissian, PhD, ACNP, CLS, AACC, FAHA
This study provides clarity regarding women with adverse pregnancy outcomes. A women who will experience gestational diabetes, independent of whether or not she later develops type 2 diabetes, is at increased risk of an ischemic event within 10 years of pregnancy. That is very striking. There are certain assumptions that many of us as providers and researchers make, that these women might go on to develop type 2 diabetes and then look very similar to other patients with CVD. What we need to understand is that they are at early risk for CVD. In looking for the development of type 2 diabetes, we are probably going to be too late to reduce their CV risk.
In this analysis, women with a gestational diabetes diagnosis had other risk markers identified within 3 months postpartum, including dyslipidemia, elevations in C-reactive protein and metabolic syndrome. We start to see a clustering of these risk markers very early, which reinforces the idea that we must CV risk-stratify these women right after delivery.
Women will benefit from early CV risk assessment as soon as they are done lactating. This should include screening for familial hyperlipidemia and for other lipid disorders such high triglycerides and low HDL cholesterol which were mentioned in the article. Completing early CV risk assessment, intervening on modifiable risk factors and encouraging a healthy lifestyle such as maintaining a healthy weight, not smoking and following a Mediterranean-style diet can positively alter a women’s CV health trajectory. We could ultimately change their CV risk trajectory altogether, with the interventions that we already have.
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