Women's Heart Notes

Hypertensive disorders during pregnancy: A window into future CV risk

Pregnancy is a time of profound change during a woman’s life. A multitude of metabolic and hemodynamic changes occur during the antepartum period that are designed to accommodate growing fetal needs. However, under the stress of the pregnant state, these processes can become maladaptive.

Among such conditions, hypertensive disorders diagnosed during pregnancy can lead to significant morbidity and mortality for mother and child. These conditions are defined as elevated BP diagnosed at more than 20 weeks’ gestational age without signs of end-organ damage (gestational hypertension) or preeclampsia/eclampsia with associated signs of end-organ dysfunction and/or seizure.

Increased CV risk

Although the potential obstetric and neonatal complications are well recognized, the potential for these conditions serving as a marker for future CV risk are perhaps less appreciated. It is known that women with hypertensive disorders of pregnancy are at higher risk for future development of chronic hypertension. However, these hypertensive conditions may also provide insight into future risk for other CV and associated conditions.

In a study published in JAMA in 2016, more than 1 million women in Denmark with a history of a hypertensive disorder during pregnancy but without pre-existing CVD or diabetes were followed for up to 3 decades. These women were found to have a small but statistically significant higher risk for cardiomyopathy after the postpartum period compared with women who remained normotensive throughout pregnancy. On average, there was approximately a twofold risk for cardiomyopathy for those with a hypertensive pregnancy condition independent of potential confounding traditional cardiac risk factors such as obesity, diabetes or ischemic heart disease.

In another recent study, relatively young women with a history of hypertension during pregnancy had evidence of poor cognitive performance and signs of brain atrophy by neuroimaging decades after childbirth. It is thought that these findings may provide insight into the elevated long-term risk for stroke in these patients. These risk associations may even extend to those women with prehypertension during pregnancy as evidenced by a recent study from Lei and colleagues, which assessed the diastolic BP trajectories of several hundred pregnant women. The researchers found that antepartum prehypertension was associated with increased risk for metabolic syndrome after delivery, and this could mediate long-term CV risk.

Another opportunity to assess future risk

Ki Park, MD, MS, FSCAI
Ki Park

Although the exact mechanisms driving these associations remain mostly unknown, it is apparent that the pregnant state and associated “stress” provides an opportunity to assess for future CV risk beyond just the more immediate postpartum period.

Current American College of Cardiology and American College of Obstetricians and Gynecologists guidelines recommend that women with a history of a hypertensive disorder during pregnancy should undergo routine screening for modifiable CV risk factors, which may prompt early intervention. Providers should be aware of these recommendations, and future research should continue to focus on mechanisms potentially driving these conditions.

Editor’s Note: This is a new column that will be printed regularly in Cardiology Today. This column is intended to inform readers of up-to-date topics within the area of women’s heart health.

Disclosure: Park reports no relevant financial disclosures.

Pregnancy is a time of profound change during a woman’s life. A multitude of metabolic and hemodynamic changes occur during the antepartum period that are designed to accommodate growing fetal needs. However, under the stress of the pregnant state, these processes can become maladaptive.

Among such conditions, hypertensive disorders diagnosed during pregnancy can lead to significant morbidity and mortality for mother and child. These conditions are defined as elevated BP diagnosed at more than 20 weeks’ gestational age without signs of end-organ damage (gestational hypertension) or preeclampsia/eclampsia with associated signs of end-organ dysfunction and/or seizure.

Increased CV risk

Although the potential obstetric and neonatal complications are well recognized, the potential for these conditions serving as a marker for future CV risk are perhaps less appreciated. It is known that women with hypertensive disorders of pregnancy are at higher risk for future development of chronic hypertension. However, these hypertensive conditions may also provide insight into future risk for other CV and associated conditions.

In a study published in JAMA in 2016, more than 1 million women in Denmark with a history of a hypertensive disorder during pregnancy but without pre-existing CVD or diabetes were followed for up to 3 decades. These women were found to have a small but statistically significant higher risk for cardiomyopathy after the postpartum period compared with women who remained normotensive throughout pregnancy. On average, there was approximately a twofold risk for cardiomyopathy for those with a hypertensive pregnancy condition independent of potential confounding traditional cardiac risk factors such as obesity, diabetes or ischemic heart disease.

In another recent study, relatively young women with a history of hypertension during pregnancy had evidence of poor cognitive performance and signs of brain atrophy by neuroimaging decades after childbirth. It is thought that these findings may provide insight into the elevated long-term risk for stroke in these patients. These risk associations may even extend to those women with prehypertension during pregnancy as evidenced by a recent study from Lei and colleagues, which assessed the diastolic BP trajectories of several hundred pregnant women. The researchers found that antepartum prehypertension was associated with increased risk for metabolic syndrome after delivery, and this could mediate long-term CV risk.

Another opportunity to assess future risk

Ki Park, MD, MS, FSCAI
Ki Park

Although the exact mechanisms driving these associations remain mostly unknown, it is apparent that the pregnant state and associated “stress” provides an opportunity to assess for future CV risk beyond just the more immediate postpartum period.

Current American College of Cardiology and American College of Obstetricians and Gynecologists guidelines recommend that women with a history of a hypertensive disorder during pregnancy should undergo routine screening for modifiable CV risk factors, which may prompt early intervention. Providers should be aware of these recommendations, and future research should continue to focus on mechanisms potentially driving these conditions.

Editor’s Note: This is a new column that will be printed regularly in Cardiology Today. This column is intended to inform readers of up-to-date topics within the area of women’s heart health.

Disclosure: Park reports no relevant financial disclosures.