Adverse Pregnancy Outcomes and CVD Risk

Parikh NI, Gonzalez JM, Anderson CA, et al.
Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women. A Scientific Statement From the American Heart Association. Circulation 2021;Mar 29:[Epub ahead of print].

The following are key points to remember from the American Heart Association Scientific Statement on adverse pregnancy outcomes (APOs) and cardiovascular disease (CVD) risk: unique opportunities for CVD prevention in women:

  1. APOs such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small for gestational age delivery, placental abruption, and pregnancy loss increase a woman's risk of developing CVD risk factors and later CVD (fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, heart failure).
  2. A history of APOs should be included as part of CVD risk assessment in women. The 2018 cholesterol treatment guidelines consider APOs as CVD risk enhancers for deciding on use of statin for CVD prevention.
  3. The addition of APOs to standard CVD risk assessment tools have not resulted in significant reclassification; however, the incremental predictive capacity of APOs is limited because of the high prevalence of conventional CVD risk factors among middle-aged and older women with prior APOs.
  4. Lactation and breast-feeding may lower a woman's later cardiometabolic risk. Breast-feeding has been associated with a lower risk of early atherosclerosis, that was independent of lifestyle behaviors. Longer duration of breast-feeding is associated with lower risk of incident hypertension during middle age (40-49 years).
  5. Black and Asian women experience a higher proportion of APOs, with more severe clinical presentation and worse outcomes. For instance, the case fatality rate for pre-eclampsia is 2.7 times higher among Black women than among White women.
  6. During pregnancy, low-dose aspirin is recommended for the prevention of pre-eclampsia in women at increased risk of pre-eclampsia (women with a history of pre-eclampsia, multifetal gestation, renal disease, autoimmune disease, diabetes, chronic hypertension, etc.).
  7. The postpartum period (also referred to as the Fourth Trimester) should be considered an opportunity to focus on lifestyle choices that optimize cardiovascular health including weight management, smoking cessation, physical activity, and nutrition. In particular, women with a history of pre-eclampsia are recommended to have evaluation of CVD risk with monitoring of blood pressure, lipids, fasting glucose, and body mass index.
  8. Additional studies that include the use of aspirin, statins, and metformin could be useful in primary CVD prevention among women with a history of an APO.
  9. Health care systems need to improve transitions of care for women with APOs. Strategies are needed to: 1) identify women at risk, 2) facilitate transfer of care between the obstetrics and primary care teams, and 3) initiate targeted strategies for risk reduction.
  10. Access to health care and insurance coverage, along with Medicaid expansion, are important methods for improving postpartum follow-up in order to reduce the long-term risk of CVD.

Clinical Topics: Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Exercise, Hypertension

Keywords: Abruptio Placentae, Aspirin, Atherosclerosis, Blood Pressure, Breast Feeding, Cholesterol, Coronary Disease, Diabetes, Gestational, Exercise, Gestational Age, Glucose, Health Services Accessibility, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Pregnancy-Induced, Infant, Newborn, Lactation, Life Style, Lipids, Metabolic Syndrome, Metformin, Peripheral Vascular Diseases, Postpartum Period, Pre-Eclampsia, Pregnancy, Pregnancy Outcome, Premature Birth, Primary Prevention, Risk Assessment, Risk Factors, Risk Reduction Behavior, Smoking Cessation, Stroke, Vascular Diseases

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