Women With Hypertension During Pregnancy Face Higher CVD Risks

Women with hypertensive disorders of pregnancy (HDP) were at a significant risk for developing new cardiovascular disease (CVD) within a couple of years of giving birth, a researcher reported.

Within 2 years postpartum, patients with HDP had almost two times the risk for cerebrovascular disease, nearly three times the risk for cardiomyopathy and heart failure (HF), and seven times the risk for chronic hypertension (HTN), according to Christina Ackerman-Banks, MD, of Baylor College of Medicine in Houston.

In a longitudinal, population-based study, the cumulative incidence of new chronic HTN over the first 24 months post-partum was 1.5% for women without HDP versus 9.7% for women with HDP, for an adjusted hazard ratio of 7.29 (95% CI 6.57-8.09), she reported in a presentation at the Society for Maternal-Fetal Medicine Annual Pregnancy Meeting.

Again comparing women without HDP to those with HDP, the latter had higher risks for:

• Cerebrovascular disease: adjusted HR 1.43 (95% CI 1.07-1.91)
• Cardiomyopathy: adjusted HR 2.90 (95% CI 1.96-4.27)
• HF: adjusted HR 2.81 (95% CI 1.90-4.15)
• Severe CVD: adjusted HR 1.90 (95% CI 1.54-2.36)

“Collaboration with primary care physicians and cardiologists and advocacy efforts for expansion of maternity care beyond the initial postpartum period is critical,” Ackerman-Banks stated.

She noted that while HDP has been linked with later CVD in previous research, few studies have followed women diagnosed with the disorder for more than 6 months to a year, and those findings have been inconclusive. Ackerman-Banks and colleagues wanted to determine if definitive changes in heart health would appear in what they called the “[u]nique time period of immediate 24 months after delivery.”

They used the Maine Health Data Organization database from 2007-2019 and looked at electronic health records (EHRs) for deliveries paid for by either public or private insurance that also had EHRs of inpatient and outpatient visits. They included women having a first child, or those who have had more than one child, and live births and stillbirths.

Using ICD 9/ICD 10 hospital codes, the researchers examined claims involving gestation of more than 20 weeks, until 6 weeks postpartum, specifically focusing on cases involving gestational HTN, pre-eclampsia without severe features, pre-eclampsia with severe features, and one case of eclampsia.

The study population consisted of 107,812 women without HDP and 15,313 women with HDP. Mean maternal age for the total population was about 28 and the majority lived in rural areas. The stillbirth rate was about 0.5%, and half of the women with HDP were on Medicaid as were a little over half of those without HDP.

Ackerman-Banks reported the following baseline characteristics at delivery for women without HDP versus those with HDP:

• Preterm delivery: 7.5% vs 23.4%
• C-section: 21.7% vs 41.3%
• Pre-existing HTN: 2.4% vs 6.0%
• Pre-existing diabetes: 3.2% vs 36.4%

Follow-up was done out to 24 months for individual CVD diagnoses.

Study limitations included lack of generalizability and no self-reported data on social determinants of healthcare, according to the researchers.

Michael Honigberg, MD, of Massachusetts General Hospital/Harvard Medical School in Boston, told MedPage Today that “the key thing that these findings add to our knowledge is how early these excess rates of cardiovascular disorders emerge.”

“We have known for about 20 years that HDP was associated with an increased risk of coronary artery disease, and within the last 5 or 6 years we have realized that that signal begins to emerge within the first decade after delivery, and it persists into later life. Now with this study, we see this signal within 24 months,” stated Honigberg, who also is an American College of Cardiology spokesperson.

He pointed out that women with pre-eclampsia are at heightened risk of peripartum cardiomyopathy, but that the current study indicated that the cardiomyopathy develops soon after delivery.

“We also know that some women with HDP go on to develop chronic HTN, and that can lead to the increase seen in cerebrovascular events,” stated Honigberg, who was not involved in the study.

However, he cautioned that the management path for patients with HDP was not clear cut. “It would not be possible for every women with this disorder [HDP] to see a cardiologist because there just isn’t enough capacity in the system to accommodate all of these patients,” he explained. “The consensus in the field is that women who experience these HDPs need very close follow-up…to make sure their elevated blood pressure returns to pre-pregnancy baseline and avoid postpartum complications that drive hospital readmission…and…to work with patients for lifestyle modifications to enhance healthy dieting, weight loss, and exercise, and get plugged into long-term primary care.”

He added that “a lot of these women will often go for years without seeing a primary care physician after delivery because they are trying to raise children and they generally feel well. But if we could find those highest at-risk patients…then we would have a population that could be referred to cardiology.”