Hypertensive Disorders of Pregnancy and Maternal CVD Risk

May 11, 2022
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Authors:
Stuart JJ, Tanz LJ, Rimm EB, et al.
Citation:
Cardiovascular Risk Factors Mediate the Long-Term Maternal Risk Associated With Hypertensive Disorders of Pregnancy. J Am Coll Cardiol 2022;79:1901-1913.
Summary By:
Melinda Davis, MD, FACC

Quick Takes

  • Women with hypertensive disorders of pregnancy (HDP) are at increased risk for developing CVD.
  • The development of CVD in women with HDP is mediated by the development of established CVD risk factors.
  • Women with a history of HDP should be screened for CVD risk factors.

Study Questions:

What proportion of the increased cardiovascular disease (CVD) risk known to be associated with hypertensive disorders of pregnancy (HDP) can be attributed to other established CVD risk factors?

Methods:

The Nurses’ Health Study II was queried for parous participants without CVD (n = 60,379). To evaluate the relationship between HDP and CVD, Cox proportional hazard models were used, with adjustment for confounders such as pre-pregnancy body mass index (BMI), smoking, and family history. The difference method was used to evaluate the proportion jointly accounted for by chronic hypertension, hypercholesterolemia, type 2 diabetes, and changes in BMI.

Results:

Compared to women with normotensive pregnancies, women with HDP in their first pregnancy subsequently had a 63% higher rate of CVD (95% confidence interval, 1.37-1.94); however, 64% of this association was mediated by established CVD risk factors. Women with a history of pre-eclampsia were at higher risk for CVD than women with gestational hypertension. Among women with pre-eclampsia, 57% of the increased CVD risk was mediated by the development of established CVD risk factors (84% for those with gestational hypertension).

Conclusions:

The development of CVD risk factors after a pregnancy complicated by hypertension or pre-eclampsia explained a large proportion of the CVD risk (84% and 57%, respectively). The authors recommend screening women with a history of HDP for development of chronic hypertension, hypercholesterolemia, type 2 diabetes, and overweight/obesity.

Perspective:

Several prior studies have highlighted the increased long-term risk of CVD among women with a history of HDP. The relative contribution of other established CVD risk factors that arise over time has been unclear. The current study adds to our understanding by demonstrating that a large proportion of CVD risk is related to the development of established CVD risk factors; this likely explains why prior attempts to add HDP to established risk prediction tools have not resulted in significant reclassification of risk. Clinicians should take a reproductive history when assessing CVD risk. Women with HDP should have careful screening for the development of CVD risk factors.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Vascular Medicine, Homozygous Familial Hypercholesterolemia, Hypertension, Smoking

Keywords: Body Mass Index, Cardiovascular Diseases, Diabetes Mellitus, Type 2, Heart Disease Risk Factors, Hypercholesterolemia, Hypertension, Pregnancy-Induced, Obesity, Overweight, Pre-Eclampsia, Pregnancy, Primary Prevention, Reproductive History, Risk Factors, Smoking, Women


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