Kardiovaskuläre Risikoreduktion bei Frauen mit Zustand nach hypertensiven Schwangerschaftserkrankungen – eine prospektive, randomisierte, kontrollierte Interventionsstudie

Zusammenfassung

Hintergrund Frauen mit Z. n. hypertensiven Schwangerschaftserkrankungen haben ein deutlich erhöhtes Lebenszeitrisiko für kardiovaskuläre Morbidität und Mortalität. Die arterielle Steifigkeit gilt dabei als ein Zielparameter für die Reduktion des kardiovaskulären Risikos und kann durch Lebensstilveränderungen modifiziert werden.

Methoden Im Rahmen einer prospektiven, randomisierten, kontrollierten Interventionsstudie wurde beginnend 6 Wochen post partum der Effekt einer Ernährungsintervention kombiniert mit einem 6-monatigen intensiven Herz-Kreislauf-Trainingsprogramm auf die arterielle Steifigkeit mittels Pulswellengeschwindigkeit (PWV) bei 38 Frauen mit schwerer hypertensiver Schwangerschaftserkrankung ([Pfropf-]Präeklampsie und/oder HELLP-Syndrom) untersucht. Ebenso wurde als Referenz eine Gruppe mit postpartalen Frauen ohne Schwangerschaftskomplikationen oder bekanntem kardiovaskulären Risiko gebildet und die arterielle Steifigkeit mittels PWV am Entbindungszeitpunkt untersucht. Die PWV wurde in der Interventions- und Kontrollgruppe innerhalb einer Woche nach Entbindung sowie nach 32 Wochen (6 Wochen + 6 Monate) bestimmt. Zusätzlich wurde eine Machbarkeitsanalyse durchgeführt.

Ergebnisse 29 von 38 Frauen mit schwerer hypertensiver Schwangerschaftserkrankung sowie 38 postpartale Frauen der Referenzgruppe wurden in die Analyse eingeschlossen (Interventionsgruppe n = 14; Kontrollgruppe n = 15; Referenzgruppe n = 38). Die Adhärenz zur a) Ernährungsberatung und b) dem intensiven Herz-Kreislauf-Trainingsprogramm betrug 73% bzw. 79%. Es zeigte sich ein klinisch relevanter Unterschied (d = 0,65) in der Pulswellengeschwindigkeit nach 6 Monaten zwischen der Interventions- und Kontrollgruppe (6,36 ± 0,76 vs. 7,33 ± 2,25 m/s; Gruppe × Zeit: p = 0,632). Die PWV der Interventionsgruppe entsprach am Studienende der Referenzgruppe (6,36 ± 0,76 m/s vs. 6,5 ± 0,70; d = 0,19), währenddessen sich die Werte der Kontrollgruppe deutlich von selbiger unterschieden (7,33 ± 2,25 m/s; d = 0,56).

Schlussfolgerung Die Studie dokumentiert die Machbarkeit einer Lifestyleintervention mit körperlichem Training nach dem Wochenbett (Start 6 Wochen post partum). Dabei zeigte die Intervention einen relevanten klinischen Effekt durch Senkung der arteriellen Steifigkeit auf das Niveau der Referenzgruppe. Bevor diese Intervention in den Versorgungs- und Präventionsstandard übernommen werden kann, müssen Follow-up-Studien diese Ergebnisse und mittelfristige Effekte auf das kardiovaskuläre Risiko bestätigen.

Schlüsselwörter

Präeklampsie - HELLP-Syndrom - arterielle Steifigkeit - Pulswellengeschwindigkeit - kardiovaskuläres Risiko

Publication History

Received: 06 July 2020

Accepted after revision: 31 December 2020

Article published online:
09 August 2021

• References/Literatur

• 1 Umesawa M, Kobashi G. Epidemiology of hypertensive disorders in pregnancy: prevalence, risk factors, predictors and prognosis. Hypertens Res 2017; 40: 213-220 DOI: 10.1038/hr.2016.126.
• 2 Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol 2009; 113: 1299-1306 DOI: 10.1097/AOG.0b013e3181a45b25.
• 3 Khan KS, Wojdyla D, Say L. et al. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367: 1066-1074 DOI: 10.1016/S0140-6736(06)68397-9.
• 4 Say L, Chou D, Gemmill A. et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2: e323-e333 DOI: 10.1016/S2214-109X(14)70227-X.
• 5 Vogel JP, Souza JP, Mori R. et al. Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG 2014; 121 (Suppl. 01) 76-88 DOI: 10.1111/1471-0528.12633.
• 6 Wu P, Haththotuwa R, Kwok CS. et al. Preeclampsia and Future Cardiovascular Health: A Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes 2017; DOI: 10.1161/CIRCOUTCOMES.116.003497.
• 7 Leon LJ, McCarthy FP, Direk K. et al. Preeclampsia and Cardiovascular Disease in a Large UK Pregnancy Cohort of Linked Electronic Health Records: A CALIBER Study. Circulation 2019; 140: 1050-1060 DOI: 10.1161/CIRCULATIONAHA.118.038080.
• 8 Vikse BE, Irgens LM, Leivestad T. et al. Preeclampsia and the risk of end-stage renal disease. N Engl J Med 2008; 359: 800-809 DOI: 10.1056/NEJMoa0706790.
• 9 Vikse BE, Hallan S, Bostad L. et al. Previous preeclampsia and risk for progression of biopsy-verified kidney disease to end-stage renal disease. Nephrol Dial Transplant 2010; 25: 3289-3296 DOI: 10.1093/ndt/gfq169.
• 10 Naghavi M, Abajobir AA, Abbafati C. et al. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390: 1151-1210 DOI: 10.1016/S0140-6736(17)32152-9.
• 11 destatis. Herz-Kreislauf-Erkrankungen verursachen die höchsten Kosten (September 2017). Accessed April 06, 2020 at: https://www.destatis.de/DE/Presse/Pressemitteilungen/2017/09/PD17_347_236.html
• 12 destatis. Zahl der Todesfälle im Jahr 2015 um 6,5 % gestiegen (Januar 2017). Accessed April 06, 2020 at: http://www.destatis.de/DE/Presse/Pressemitteilungen/2017/01/PD17_022_232.html
• 13 Deharde D, Klockenbusch W, Schmitz R. et al. Hydroxychloroquine as a Preventive and Therapeutic Option in Preeclampsia – a Literature Review. Geburtshilfe Frauenheilkd 2020; 80: 679-685 DOI: 10.1055/a-1170-5145.
• 14 Scholten RR, Thijssen DJ, Lotgering FK. et al. Cardiovascular effects of aerobic exercise training in formerly preeclamptic women and healthy parous control subjects. Am J Obstet Gynecol 2014; 211: 516.e1-516.e11 DOI: 10.1016/j.ajog.2014.04.025.
• 15 Hu FB, Stampfer MJ, Solomon C. et al. Physical activity and risk for cardiovascular events in diabetic women. Ann Intern Med 2001; 134: 96-105
• 16 Giroir BP, Wright D. Physical Activity Guidelines for Health and Prosperity in the United States. JAMA 2018; 320: 1971-1972 DOI: 10.1001/jama.2018.16998.
• 17 Piepoli MF, Hoes AW, Agewall S. et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37: 2315-2381 DOI: 10.1093/eurheartj/ehw106.
• 18 Cupples ME, McKnight A. Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk. BMJ 1994; 309: 993-996 DOI: 10.1136/bmj.309.6960.993.
• 19 World Health Organization. Diet, Nutrition, and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert Consultation. Geneva: World Health Organization; 2003
• 20 Badimon L, Chagas P, Chiva-Blanch G. Diet and Cardiovascular Disease: Effects of Foods and Nutrients in Classical and Emerging Cardiovascular Risk Factors. Curr Med Chem 2019; 26: 3639-3651 DOI: 10.2174/0929867324666170428103206.
• 21 Ros E, Martinez-Gonzalez MA, Estruch R. et al. Mediterranean diet and cardiovascular health: Teachings of the PREDIMED study. Adv Nutr 2014; 5: 330S-336S DOI: 10.3945/an.113.005389.
• 22 Enkhmaa D, Wall D, Mehta PK. et al. Preeclampsia and Vascular Function: A Window to Future Cardiovascular Disease Risk. J Womens Health (Larchmt) 2016; 25: 284-291 DOI: 10.1089/jwh.2015.5414.
• 23 Cain MA, Salemi JL, Tanner JP. et al. Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes. Am J Obstet Gynecol 2016; 215: 484.e1-484.e14 DOI: 10.1016/j.ajog.2016.05.047.
• 24 Gilmore LA, Klempel-Donchenko M, Redman LM. Pregnancy as a window to future health: Excessive gestational weight gain and obesity. Semin Perinatol 2015; 39: 296-303 DOI: 10.1053/j.semperi.2015.05.009.
• 25 Catov JM, Margerison-Zilko C. Pregnancy as a window to future health: short-term costs and consequences. Am J Obstet Gynecol 2016; 215: 406-407 DOI: 10.1016/j.ajog.2016.06.060.
• 26 Sander GE, Giles TD. Vascular stiffness is a biomarker of global cardiovascular risk. J Clin Hypertens (Greenwich) 2014; 16: 625-626 DOI: 10.1111/jch.12380.
• 27 Zieman SJ, Melenovsky V, Kass DA. Mechanisms, pathophysiology, and therapy of arterial stiffness. Arterioscler Thromb Vasc Biol 2005; 25: 932-943 DOI: 10.1161/01.ATV.0000160548.78317.29.
• 28 Foo FL, McEniery CM, Lees C. et al. Assessment of arterial function in pregnancy: recommendations of the International Working Group on Maternal Hemodynamics. Ultrasound Obstet Gynecol 2017; 50: 324-331 DOI: 10.1002/uog.17565.
• 29 Elvan-Taspinar A, Bots ML, Franx A. et al. Stiffness of the arterial wall, joints and skin in women with a history of pre-eclampsia. J Hypertens 2005; 23: 147-151 DOI: 10.1097/00004872-200501000-00025.
• 30 Christensen M, Kronborg CJs, Knudsen UB. Preeclampsia and arterial stiffness – A 10-year follow up of previous preeclamptic women. Pregnancy Hypertension: An International Journal of Womenʼs Cardiovascular Health 2015; 5: 72-73 DOI: 10.1016/j.preghy.2014.10.145.
• 31 Rath W, Tsikouras P, Stelzl P. HELLP Syndrome or Acute Fatty Liver of Pregnancy: A Differential Diagnostic Challenge: Common Features and Differences. Geburtshilfe Frauenheilkd 2020; 80: 499-507 DOI: 10.1055/a-1091-8630.
• 32 Stepan H, Kuse-Föhl S, Klockenbusch W. et al. Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013). Geburtshilfe Frauenheilkd 2015; 75: 900-914 DOI: 10.1055/s-0035-1557924.
• 33 Pucci G, Cheriyan J, Hubsch A. et al. Evaluation of the Vicorder, a novel cuff-based device for the noninvasive estimation of central blood pressure. J Hypertens 2013; 31: 77-85 DOI: 10.1097/HJH.0b013e32835a8eb1.
• 34 Davies JM, Bailey MA, Griffin KJ. et al. Pulse wave velocity and the non-invasive methods used to assess it: Complior, SphygmoCor, Arteriograph and Vicorder. Vascular 2012; 20: 342-349 DOI: 10.1258/vasc.2011.ra0054.
• 35 Shahin Y, Barakat H, Barnes R. et al. The Vicorder device compared with SphygmoCor in the assessment of carotid-femoral pulse wave velocity in patients with peripheral arterial disease. Hypertens Res 2013; 36: 208-212 DOI: 10.1038/hr.2012.144.
• 36 Parikh JD, Hollingsworth KG, Kunadian V. et al. Measurement of pulse wave velocity in normal ageing: comparison of Vicorder and magnetic resonance phase contrast imaging. BMC Cardiovasc Disord 2016; 16: 50 DOI: 10.1186/s12872-016-0224-4.
• 37 Hickson SS, Butlin M, Broad J. et al. Validity and repeatability of the Vicorder apparatus: a comparison with the SphygmoCor device. Hypertens Res 2009; 32: 1079-1085 DOI: 10.1038/hr.2009.154.
• 38 Chan D, Beska B, Gu S. et al. 161 The association of non-invasive cardiovascular parameters on adverse outcomes in older patients following non-ST elevation acute coronary syndrome undergoing invasive care. Heart 2019; 105: A134-A135 DOI: 10.1136/heartjnl-2019-BCS.158.
• 39 Kis E, Cseprekál O, Kerti A. et al. Measurement of pulse wave velocity in children and young adults: a comparative study using three different devices. Hypertension Research 2011; 34: 1197-1202 DOI: 10.1038/hr.2011.103.
• 40 Kracht D, Shroff R, Baig S. et al. Validating a New Oscillometric Device for Aortic Pulse Wave Velocity Measurements in Children and Adolescents. Am J Hypertens 2011; 24: 1294-1299 DOI: 10.1038/ajh.2011.147.
• 41 Redheuil A, Bensalah M, Kachenoura N. et al. Measuring aortic distensibility with cmr using central pressures estimated in the magnet: comparison with carotid and peripheral pressures. J Cardiovasc Magn Reson 2011; 13: P27 DOI: 10.1186/1532-429X-13-S1-P27.
• 42 Pucci G, Cheriyan J, Hubsch A. et al. A comparison of the Vicorder apparatus with SphygmoCor device for the non-invasive assessment of aortic blood pressure: an invasive validation study. Artery Research 2010; 4: 146 DOI: 10.1016/j.artres.2010.10.167.
• 43 Skidmore Medical Limited. Präsentation „Vicorder(C) – Arterielle Steifigkeit – PWV – PWA“. 2009 – 2011.
• 44 Dickhuth HH, Huonker M, Münzel T, Drexler H, Berg A, Keul J. Individual Anaerobic Threshold for Evaluation of Competitive Athletes and Patients with Left Ventricular Dysfunction. In: Bachl N, Graham TE, Löllgen H, eds. Advances in Ergometry. Berlin, Heidelberg: Springer; 1991
• 45 Deutsche Gesellschaft für Gynäkologie und Geburtshilfe. S1-Leitlinie: Diagnostik und Therapie hypertensiver Schwangerschaftserkrankungen. 2013. Accessed December 16, 2020 at: https://präeklampsie-hellp.de/source/Infotexte/015-018l_S1_Diagnostik_Therapie_hypertensiver_Schwangerschaftserkrankungen_2014-01-1.pdf
• 46 Winkler G, Doring A. Validation of a short qualitative food frequency list used in several German large scale surveys. Z Ernahrungswiss 1998; 37: 234-241 DOI: 10.1007/pl00007377.
• 47 Kaihura C, Savvidou MD, Anderson JM. et al. Maternal arterial stiffness in pregnancies affected by preeclampsia. Am J Physiol Heart Circ Physiol 2009; 297: H759-H764 DOI: 10.1152/ajpheart.01106.2008.
• 48 Ashor AW, Lara J, Siervo M. et al. Effects of Exercise Modalities on Arterial Stiffness and Wave Reflection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLoS One 2014; 9: e110034 DOI: 10.1371/journal.pone.0110034.
• 49 Hartmann A, Herzog T, Drinkmann A. Psychotherapy of bulimia nervosa: what is effective? A meta-analysis. J Psychosom Res 1992; 36: 159-167 DOI: 10.1016/0022-3999(92)90024-v.
• 50 Cohen J. Statistical Power Analysis for the Behavioral Sciences. New York: Taylor & Francis; 2013
• 51 Richardson JTE. Eta squared and partial eta squared as measures of effect size in educational research. Educational Research Review 2011; 6: 135-147 DOI: 10.1016/j.edurev.2010.12.001.
• 52 Reference Values for Arterial Stiffnessʼ Collaboration. Determinants of pulse wave velocity in healthy people and in the presence of cardiovascular risk factors: ‘establishing normal and reference values’. Eur Heart J 2010; 31: 2338-2350 DOI: 10.1093/eurheartj/ehq165.
• 53 Wallis AB, Saftlas AF, Hsia J. et al. Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, United States, 1987–2004. Am J Hypertens 2008; 21: 521-526 DOI: 10.1038/ajh.2008.20.
• 54 Kontis V, Bennett JE, Mathers CD. et al. Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble. Lancet 2017; 389: 1323-1335 DOI: 10.1016/s0140-6736(16)32381-9.
• 55 Honigberg MC, Zekavat SM, Aragam K. et al. Long-Term Cardiovascular Risk in Women With Hypertension During Pregnancy. J Am Coll Cardiol 2019; 74: 2743-2754 DOI: 10.1016/j.jacc.2019.09.052.
• 56 Schildberger B, Linzner D, Hehenberger L. et al. Influence of Maternal Age on Selected Obstetric Parameters. Geburtshilfe Frauenheilkd 2019; 79: 1208-1215 DOI: 10.1055/a-0859-0826.
• 57 Viana Pinto P, Rei M, Machado AP. et al. Preeclampsia and future cardiovascular risk: are women and general practitioners aware of this relationship? The experience from a portuguese centre. Obstet Gynecol Int 2014; 2014: 531539 DOI: 10.1155/2014/531539.
• 58 Gaston A, Gammage KL. The effectiveness of a health-based message on pregnant womenʼs intentions to exercise postpartum. J Reprod Infant Psychol 2011; 29: 162-169 DOI: 10.1080/02646838.2010.541230.
• 59 Vlachopoulos C, Aznaouridis K, Stefanadis C. Prediction of cardiovascular events and all-cause mortality with arterial stiffness: a systematic review and meta-analysis. J Am Coll Cardiol 2010; 55: 1318-1327 DOI: 10.1016/j.jacc.2009.10.061.
• 60 Sjöström M, Oja P, Hagströmer M. et al. Health-enhancing physical activity across European Union countries: the Eurobarometer study. J Public Health 2006; 14: 291-300 DOI: 10.1007/s10389-006-0031-y.
• 61 DSSV-Arbeitgeberverband deutscher Fitness- und Gesundheits-Anlagen. Körperliche Aktivität senkt Gesundheitsausgaben um ca. 21 Mrd. EUR (Februar 2017). Accessed June 12, 2020 at: https://www.dssv.de/index.php?eID=dumpFile&t=f&%20f=3980&%20token=c38a698fe359a019e92c62acfb5d560433e78435
• 62 Jones NRV, Conklin AI, Suhrcke M. et al. The Growing Price Gap between More and Less Healthy Foods: Analysis of a Novel Longitudinal UK Dataset. PLoS One 2014; 9: e109343 DOI: 10.1371/journal.pone.0109343.
• 63 Silva LM, Coolman M, Steegers EA. et al. Low socioeconomic status is a risk factor for preeclampsia: the Generation R Study. J Hypertens 2008; 26: 1200-1208 DOI: 10.1097/HJH.0b013e3282fcc36e.
• 64 Müller MJ, Landsberg B, Plachta-Danielzik S. et al. Soziale Ungleichheit im Übergewicht. Adipositas – Ursachen, Folgeerkrankungen, Therapie 2009; 03: 88-96 DOI: 10.1055/s-0037-1618667.
• 65 Morris EA, Hale SA, Badger GJ. et al. Pregnancy induces persistent changes in vascular compliance in primiparous women. Am J Obstet Gynecol 2015; 212: 633.e1-633.e6 DOI: 10.1016/j.ajog.2015.01.005.
• 66 Foo FL, McEniery CM, Lees C. et al. Assessment of arterial function in pregnancy: recommendations of the International Working Group on Maternal Hemodynamics. Ultrasound Obstet Gynecol 2017; 50: 324-331 DOI: 10.1002/uog.17565.
• 67 Kalapotharakos G, Salehi D, Steding-Ehrenborg K. et al. Cardiovascular effects of severe late-onset preeclampsia are reversed within six months postpartum. Pregnancy Hypertens 2020; 19: 18-24 DOI: 10.1016/j.preghy.2019.12.005.
• 68 Banala C, Moreno S, Cruz Y. et al. Impact of the ACOG guideline regarding low-dose aspirin for prevention of superimposed preeclampsia in women with chronic hypertension. Am J Obstet Gynecol 2020; 223: 419.e1-419.e16 DOI: 10.1016/j.ajog.2020.03.004.