Garovic, Vesna D.

Abstract Thyroid dysfunction in pregnancy has been associated with hypertensive disorders of pregnancy and poor maternal and fetal outcomes. In this article, we describe two cases of significant thyroid dysfunction leading to new diagnoses of chronic hypertension in pregnancy and review physiologic changes in the thyroid gland, placenta and maternal cardiovascular system during pregnancy.

Background: Hypertension (HTN) affects almost half of the adults in the US, and most do not have their blood pressure (BP) under control. Minorities and individuals living in rural areas experience health disparities. The goal of this study was to assess the rate of BP control among adults in a large health system that included minorities and adults living in rural areas. Methods: Clinical cohort study of adults with HTN who live in Southeast Minnesota and had at least one outpatient clinic encounter within the Mayo Clinic Health System in the last 12 months (5/2021-5/2022). Data was extracted through the HTN registry of the electronic health record and included age, race, ethnicity, last office BP and any active anti-hypertensives drug use. Results: The overall rate of HTN control among 127,644 individuals with HTN, defined as an office BP < 130/80 mmHg, was 25.7%. The rates of BP control between HTN subjects living in rural (64527, 67.3%) versus urban areas (41285, 32.3 %), were significantly lower at 24.9% vs. 27% respectively, p< 0.001. A total of 8,722 (6.8%) were non-white, including 2640 Black, 1919 Asian, and 2867 Hispanics A total of 5,734 (45%) had a SBP ≥ 140 or DBP ≥ 90 mmHg and 7178 (12.5%) did not have any anti-hypertensives in their medication list. The percentage of White and Asian persons who were not on anti-hypertensives was 12.4% and 12.5%, respectively, while a larger percentage of Black (13.8%) and Hispanic (14%) persons were not (p<0.001). The corresponding percentage was 16.7% among individuals who did not disclose their race (p<0.001). Conclusion: Among hypertensive adults, BP was not at goal in most patients based on their most recent office BP measurement with a higher rate among those living in rural areas. About 12.5% were not on anti-hypertensives with a disproportionate larger percentage of Black and Hispanic compared to White and Asian persons.

Background: Preeclampsia (PE) is a pregnancy-specific hypertensive disorder which affects up to 7% of all pregnancies. It is associated with increased risk for cardiovascular disease later in life. We have recently reported increased senescence and accelerated aging in women with PE. We hypothesize that senescence burden remains after PE. The aim of this study was to compare senescence profiles, and history of individual chronic conditions and multimorbidity, a marker of accelerated aging, in women with and without a history of PE. Methods: Forty women with histories of PE and 40 with histories of normotensive pregnancy confirmed by manual chart review were age- and parity-matched. None of the women had a history of CVD at the time of recruitment. Markers of senescence (p16, p21 and Klotho) and metabolic syndrome (leptin, adiponectin) were measured and compared between women with and without histories of preeclampsia using conditional logistic regression. The rates of chronic conditions and multimorbidity between the groups were also compared. Results: Urinary Klotho/creatinine levels were significantly lower (median [IQR]: 117 [87.4, 224] vs. 205 [101, 359], respectively, p=0.042), while leptin/adiponectin ratio was significantly higher (median [IQR]: 0.25 [0.13, 0.45] vs. 0.05 [0.02, 0.12], p=0.027) among women with histories of PE compared to controls. There were no significant differences observed in plasma p21 or p16 concentrations. Women with histories of PE experienced a higher prevalence of two or more co-morbidities compared to women with normotensive pregnancies [67.5% (27/40) vs. 22.5% (9/40), p<0.05]. Results were similar after removing hypertension as a comorbidity [45% (18/40) vs. 20.0% (8/40), p<0.05]. Conclusion: Women with a history of PE had altered markers of senescence, metabolic syndrome and multimorbidity decades after PE.

Objectives Evaluate the associations between patients taking ACE inhibitors and angiotensin receptor blockers (ARBs) and their clinical outcomes after an acute viral respiratory illness (AVRI) due to COVID-19. Design Retrospective cohort. Setting The USA; 2017–2018 influenza season, 2018–2019 influenza season, and 2019–2020 influenza/COVID-19 season. Participants People with hypertension (HTN) taking an ACEi, ARB or other HTN medications, and experiencing AVRI. Main outcome measures Change in hospital admission, intensive care unit (ICU) or coronary care unit (CCU), acute respiratory distress (ARD), ARD syndrome (ARDS) and all-cause mortality, comparing COVID-19 to pre-COVID-19 influenza seasons. Results The cohort included 1 059 474 episodes of AVRI (653 797 filled an ACEi or ARB, and 405 677 other HTN medications). 58.6% were women and 72.9% with age ≥65. The ACEi/ARB cohort saw a larger increase in risk in the COVID-19 influenza season than the other HTN medication cohort for four out of five outcomes, with an additional 1.5 percentage point (pp) increase in risk of an inpatient stay (95% CI 1.2 to 1.9 pp) and of ICU/CCU use (95% CI 0.3 to 2.7 pp) as well as a 0.7 pp (0.1 to 1.2 pp) additional increase in risk of ARD and 0.9 pp (0.4 to 1.3 pp) additional increase in risk of ARDS. There was no statistically significant difference in the absolute risk of death (−0.2 pp, 95% CI −0.4 to 0.1 pp). However, the relative risk of death in 2019/2020 versus 2017/2018 for the ACEi/ARB group was larger (1.40 (1.36 to 1.44)) than for the other HTN medication cohort (1.24 (1.21 to 1.28)). Conclusions People with AVRI using ACEi/ARBs for HTN had a greater increase in poor outcomes during the COVID-19 pandemic than those using other medications to treat HTN. The small absolute magnitude of the differences likely does not support changes in clinical practice.

Beyond conventional risk factors for cardiovascular disease, women face an additional burden of sex-specific risk factors. Key stages of a woman’s reproductive history may influence or reveal short- and long-term cardiometabolic and cardiovascular trajectories. Early and late menarche, polycystic ovary syndrome, infertility, adverse pregnancy outcomes (eg, hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction), and absence of breastfeeding are all associated with increased future cardiovascular disease risk. The menopause transition additionally represents a period of accelerated cardiovascular disease risk, with timing (eg, premature menopause), mechanism, and symptoms of menopause, as well as treatment of menopause symptoms, each contributing to this risk. Differences in conventional cardiovascular disease risk factors appear to explain some, but not all, of the observed associations between reproductive history and later-life cardiovascular disease; further research is needed to elucidate hormonal effects and unique sex-specific disease mechanisms. A history of reproductive risk factors represents an opportunity for comprehensive risk factor screening, refinement of cardiovascular disease risk assessment, and implementation of primordial and primary prevention to optimize long-term cardiometabolic health in women.