Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology, University of Toronto, Toronto, ON, Canada.
Division of Endocrinology, University of Toronto, Toronto, ON, Canada; Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Lancet Diabetes Endocrinol. 2019 May;7(5):378-384. doi: 10.1016/S2213-8587(19)30077-4. Epub 2019 Mar 27.
In studies to date, gestational diabetes has consistently been associated with an increased future risk of cardiovascular disease, irrespective of the antepartum screening protocol or diagnostic criteria by which gestational diabetes is diagnosed. We reasoned that the resultant heterogeneity in the severity of dysglycaemia in women with gestational diabetes suggests that the relationship between gestational glycaemia and subsequent cardiovascular disease probably extends into the non-diagnostic range. Thus, we hypothesised that glucose screening in pregnancy would identify future risk of cardiovascular disease in women who did not have gestational diabetes.
We did a population-based cohort study using information from health-care administrative databases from the Ministry of Health and Long Term Care of Ontario (Canada). We identified all women in Ontario who had a 50 g oral glucose challenge test in pregnancy between 24 and 28 weeks gestation with a livebirth delivery between July 1, 2007, and Dec 31, 2015. Women who had a history of diabetes before pregnancy or had been previously hospitalised for cardiovascular disease were excluded. Women with a 1-h post-challenge plasma glucose concentration of 11·1 mmol/L or greater were considered to have gestational diabetes, as were women with a reading between 7·8 and 11·0 mmol/L inclusive for whom diabetes was recorded as a diagnosis on the delivery hospital record. The study population was divided into six groups based on the results of the glucose challenge test (≤4·8 mmol/L; 4·9-5·5 mmol/L; 5·6-6·2 mmol/L; 6·3-6·9 mmol/L; 7·0-7·9 mmol/L; and ≥8·0 mmol/L). The primary outcome was cardiovascular disease (a composite of hospitalisation for myocardial infarction, acute coronary syndrome, stroke, coronary artery bypass grafting, percutaneous coronary intervention, or carotid endarterectomy). All women were followed up from the index pregnancy until cardiovascular disease event, death, migration, or Sept 30, 2017, whichever came first.
259 164 women were identified as eligible for this study: 13 609 who had gestational diabetes, and 245 555 women without gestational diabetes. The women were followed up over a median 3·9 years (IQR 2·8-5·6) for the development of cardiovascular disease. Each 1 mmol/L increment in the glucose challenge test result was associated with a 13% higher risk of cardiovascular disease (after adjustment for age, ethnicity, income, and rurality, adjusted hazard ratio [HR] 1·13, 95% CI 1·04-1·22). This relationship persisted after excluding women with gestational diabetes (1·14, 1·01-1·28). In women without gestational diabetes, those with an abnormal glucose challenge test result (≥7·8 mmol/L) and those with a result between 7·2 and 7·7 mmol/L had an increased risk of cardiovascular disease (HR 1·94, 95% CI 1·29-2·92; and 1·65, 0·99-2·76, respectively), compared with those with a result of 7·1 mmol/L or less (overall p=0·003).
The relationship between gestational glycaemia and subsequent risk of cardiovascular disease extends into the normoglycaemic range. Accordingly, glucose screening in pregnancy could identify future risk of cardiovascular disease in women who do not have gestational diabetes.
None.
在迄今为止的研究中，妊娠期糖尿病与心血管疾病的未来风险增加始终相关，而不论用于诊断妊娠期糖尿病的产前筛查方案或诊断标准如何。我们推断，患有妊娠期糖尿病的女性中血糖异常的严重程度存在差异，这表明妊娠期血糖与随后的心血管疾病之间的关系可能扩展到非诊断范围。因此，我们假设在妊娠期间进行葡萄糖筛查可以识别出没有患妊娠期糖尿病的女性的未来心血管疾病风险。
我们使用安大略省卫生部和长期护理部的医疗保健管理数据库中的信息进行了一项基于人群的队列研究。我们确定了所有在 2007 年 7 月 1 日至 2015 年 12 月 31 日期间在妊娠 24 至 28 周之间进行 50g 口服葡萄糖挑战试验且分娩活婴的安大略省妇女。排除在妊娠前患有糖尿病或因心血管疾病住院治疗的妇女。1 小时后挑战试验血浆葡萄糖浓度为 11.1mmol/L 或更高的女性被认为患有妊娠期糖尿病，对于介于 7.8 和 11.0mmol/L 之间的患者，只要分娩医院记录中记录有糖尿病，也将其诊断为妊娠期糖尿病。根据葡萄糖挑战试验的结果，研究人群分为六组（≤4.8mmol/L；4.9-5.5mmol/L；5.6-6.2mmol/L；6.3-6.9mmol/L；7.0-7.9mmol/L；和≥8.0mmol/L）。主要结局是心血管疾病（心肌梗死、急性冠状动脉综合征、中风、冠状动脉旁路移植术、经皮冠状动脉介入治疗或颈动脉内膜切除术住院的复合）。所有女性均从指数妊娠开始随访，直至发生心血管疾病事件、死亡、移民或 2017 年 9 月 30 日，以先发生者为准。
确定了 259164 名符合条件的女性：13609 名患有妊娠期糖尿病，245555 名没有妊娠期糖尿病。中位随访时间为 3.9 年（IQR 2.8-5.6），以确定心血管疾病的发生情况。葡萄糖挑战试验结果每增加 1mmol/L，心血管疾病的风险就会增加 13%（调整年龄、种族、收入和农村程度后，调整后的危险比 [HR]1.13，95%CI 1.04-1.22）。这种关系在排除了妊娠期糖尿病的女性后仍然存在（1.14，1.01-1.28）。在没有妊娠期糖尿病的女性中，葡萄糖挑战试验结果异常（≥7.8mmol/L）和结果在 7.2 至 7.7mmol/L 之间的女性，心血管疾病的风险增加（HR 1.94，95%CI 1.29-2.92；和 1.65，0.99-2.76），与结果为 7.1mmol/L 或更低的女性相比（总体 p=0.003）。
妊娠期血糖与随后心血管疾病风险之间的关系扩展到正常血糖范围。因此，在妊娠期间进行葡萄糖筛查可以识别出没有患妊娠期糖尿病的女性的未来心血管疾病风险。
无。
