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Gestational Diabetes, Glycemia, and CAC in Midlife
Quick Takes
- Women with a history of gestational diabetes mellitus are at increased risk of atherosclerotic cardiovascular disease in midlife, even in the absence of glucose intolerance.
- Clinicians should take a reproductive history from patients. Women with a history of gestational diabetes likely warrant additional screening for various cardiovascular disease risk factors.
Study Questions:
What is the association between gestational diabetes mellitus (GDM) and glucose tolerance after pregnancy with coronary artery calcium (CAC) in midlife, a surrogate for cardiovascular disease (CVD)?
Methods:
The CARDIA study (Coronary Artery Risk Development in Young Adults) is a US multicenter, community-based prospective cohort of Black (50%) and White adults aged 18-30 years at baseline (1985-1986). Inclusion criteria were women without diabetes at baseline and ≥1 singleton births during follow-up. Glucose tolerance testing was performed at baseline and up to 5 times during follow-up. CAC measurements were obtained by noncontrast cardiac computed tomography at least once at years 15, 20, and 25. CAC was dichotomized as any CAC (score >0) or no CAC (score = 0). The relationship between GDM and subsequent glucose tolerance groups (normoglycemia, prediabetes, or incident diabetes) with CAC was assessed on average 14.7 years after the last birth.
Results:
Of 1,133 women (mean age 47.6 ± 4.8 years), 139 (12.3%) reported a history of GDM. CAC was present in 25% (34/139) of women with GDM versus 15% (149/994) of women without GDM. Among women without GDM, in comparison with normoglycemia, adjusted hazard ratios of CAC were 1.54 (95% confidence interval [CI], 1.06-2.24) for prediabetes and 2.17 (95% CI, 1.30-3.62) for incident diabetes. Among women with GDM, in comparison with normoglycemia and no GDM, the adjusted hazard ratios were 2.34 (95% CI, 1.34-4.09) for normoglycemia, 2.13 (95% CI, 1.09-4.17) for prediabetes, and 2.02 (95% CI, 0.98-4.19) for incident diabetes (overall p = 0.003).
Conclusions:
Women without GDM had a graded increase in risk of CAC related to worse glucose tolerance. In contrast, women with GDM had a two-fold higher risk of CAC, regardless of level of glucose tolerance, including normoglycemia.
Perspective:
Prior studies have demonstrated a strong association between GDM and subsequent development of incident diabetes. GDM is also associated with increased risk of long-term CVD, but much of this risk has been attributed to the interval development of incident diabetes. In this study, there was a two-fold higher risk of CAC (a surrogate for CVD) in midlife in women with prior GDM, even if they were normoglycemic. Possible explanations for this important finding are: 1) GDM represents a constellation of risk factors that lead to CVD even without hyperglycemia, 2) women with GDM may still have more insulin resistance and inflammation even if they maintain normoglycemia, and 3) GDM may be associated with dysmetabolism that leads to coronary atherogenesis and calcification. The results of this study serve as another reminder of the importance of taking an obstetric history for primary prevention of CVD. A history of GDM should not only prompt screening for diabetes, but enhanced CVD risk screening including blood pressure, dyslipidemia, hyperinsulinemia, and modifiable lifestyle behaviors.
Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Prevention, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Computed Tomography, Nuclear Imaging
Keywords: Atherosclerosis, Diabetes, Gestational, Diabetes Mellitus, Diagnostic Imaging, Female, Glucose, Glucose Tolerance Test, Hyperglycemia, Inflammation, Insulin Resistance, Plaque, Atherosclerotic, Prediabetic State, Pregnancy, Primary Prevention, Risk Factors, Tomography, X-Ray Computed, Women, Young Adult
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