Physician-Optimized Postpartum Hypertension Treatment - POP HT

Feb 28, 2024
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Author/Summarized by Author:
Amit Saha, MD
Summary Reviewer:
Dharam J. Kumbhani, MD, SM, FACC
Trial Sponsor:
British Heart Foundation
Date Published:
02/28/2024
Original Posted Date:
02/28/2024
References

Contribution To Literature:

The POP-HT trial showed that in women with hypertensive pregnancy, a telehealth initiative to rapidly optimize postpartum anti-HTN medications was associated with long-term, potentially beneficial changes in cardiac structure compared with usual care.

Description:

The goal of this secondary analysis was to determine the effect on cardiac remodeling of intensive, telehealth-based management of hypertension (HTN) versus usual postpartum care following hypertensive pregnancy.

Study Design

  • Randomized
  • Single-center
  • Open-label
  • Secondary analysis

Pregnant women with gestational HTN or pre-eclampsia were randomized in 1:1 fashion to anti-HTN medication adjustment by a remote team of cardiologists and obstetricians guided by minimum-daily home blood pressure (BP) readings (n = 109) or usual postpartum care comprising a family physician and/or midwife (n = 107). A transthoracic echocardiogram (TTE) was performed at baseline (days 1 to 6 postpartum) and final study visit (6 to 9 months postpartum). Cardiac magnetic resonance imaging (CMR) was performed at the final visit only.

  • Total number of enrollees: 216 with baseline TTE
  • Duration of follow-up: 9 months postpartum
  • Mean patient age: 33 years

Inclusion criteria:

  • Age ≥18 years
  • Gestational HTN (i.e., new onset at ≥20 weeks of gestation) or pre-eclampsia
  • Anti-HTN medication requirement at discharge

Exclusion criteria:

  • Significant kidney or liver disease that, in the investigator’s judgment, may limit medication adjustment
  • Chronic hypertension preceding pregnancy or 20 weeks of gestation
  • Other comorbid conditions that may affect patient safety, ability to participate, or influence results during the trial period

Other salient features/characteristics:

  • Mean antenatal BP: 118/72 mm Hg
  • Pre-eclampsia: 60%
  • Primiparous: 66%
  • Emergency cesarean section:  40%
  • Repeat TTE obtained, intervention vs. usual care: 93% vs. 80%
  • CMR obtained, intervention vs. usual care: 85% vs. 76%

Principal Findings:

Mean difference in baseline-adjusted TTE measures at 9 months, intervention vs. usual care:

  • Left ventricular ejection fraction (LVEF): 65.57% vs. 63.72%, +1.79 (95% confidence interval [CI] 0.84 to 2.75), p < 0.001
  • Relative wall thickness: 0.27 vs. 0.33, -0.06 (95% CI -0.07 to -0.05), p < 0.001
  • LV end-diastolic volume index (LVEDVi): 59.03 mL/m2 vs. 63.68 mL/m2, -4.74 (95% CI -6.23 to -3.26), p < 0.001
  • Average E/E’: 6.05 vs. 6.61, -0.52 (95% CI -0.97 to -0.06), p = 0.024
  • Left atrial volume index: 21.74 mL/m2 vs. 25.98 mL/m2, -4.36 (95% CI -5.52 to -3.21), p < 0.001

Mean difference in CMR measures at 9 months, intervention vs. usual care:

  • LVEF: 64.37% vs. 61.85%, +2.61 (95% CI 1.31 to 3.92), p < 0.001
  • Right ventricular EF: 60.93% vs. 58.32%, +2.76 (95% CI 1.44 to 4.09), p < 0.001
  • LVEDVi: 66.27 mL/m2 vs. 70.07 mL/m2, -3.87 (95% CI -6.77 to -0.98), p = 0.009
  • LV mass index: 39.18 mL/m2 vs. 45.48 mL/m2, -6.37 (95% CI -7.99 to -4.74), p < 0.001

Interpretation:

The POP-HT trial showed that a telehealth intervention of intensive anti-HTN medication titration was more effective than usual care in lowering 9-month ambulatory BP. Although exploratory and not adjusted for multiplicity, this secondary analysis demonstrates more favorable echocardiographic and CMR measures of cardiac remodeling, diastology, and biventricular systolic function in the intervention arm. Hypertensive disorders of pregnancy are associated with exaggerated and persistent LV remodeling, which in normotensive gestation typically resolves rapidly postpartum. The consequent LV hypertrophy and diastolic dysfunction is associated with subsequently developing chronic HTN and may increase long-term risk for adverse cardiovascular events. Although the absolute mean difference of each measure was small, the overall cohort was young, and these differences may compound over decades toward very different cardiac phenotypes.

Notably, only 12% of patients in this study remained on anti-HTN medication at their 6- to 9-month visit, and median treatment duration in the intervention arm was only 39 days. These results therefore suggest that early postpartum BP optimization may induce rapid cardiac remodeling associated with more favorable long-term cardiovascular risk.

References:

Kitt J, Krasner S, Barr L, et al. Cardiac Remodeling After Hypertensive Pregnancy Following Physician-Optimized Blood Pressure Self-Management: The POP-HT Randomized Clinical Trial Imaging Substudy. Circulation 2024;149:529-41.

Kitt J, Fox R, Frost A, et al. Long-Term Blood Pressure Control After Hypertensive Pregnancy Following Physician-Optimized Self-Management: The POP-HT Randomized Clinical Trial. JAMA 2023;330:1991-9.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Vascular Medicine, Hypertension, Noninvasive Imaging

Keywords: Hypertension, Pregnancy-Induced, Pre-Eclampsia


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