Complicated Pregnancies and CVD Risk: Cardiologists Can Be Part of Solution

Study after study has shown that complications during pregnancy put women at higher risk of developing cardiovascular disease, yet this knowledge isn’t routinely applied in practice. A new scientific statement released this week by the American Heart Association (AHA) drives home the point that this is a missed opportunity for risk stratification and prevention.

Published online in Circulation, the document highlights six adverse pregnancy outcomes (APOs) with known links to CVD: hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, small-for-gestational-age delivery, pregnancy loss, and placental abruption. For instance, postmenopausal women are more likely to develop atherosclerotic cardiovascular disease if they’ve experienced an APO.

Both the 2011 update to AHA guidelines for CVD prevention in women and the latest US cholesterol guidelines mention a role for APOs in risk assessment, the statement notes.

“One thing we learned,” by summarizing the evidence base, “is just how vast the literature is and how relatively consistent the findings are,” writing group chair Nisha I. Parikh, MD, MPH (University of California, San Francisco), told TCTMD. Their hope, she said, is that the statement can inform future public-health initiatives that target the needs of pregnant women.

“What I would also like to see with this statement is for cardiovascular-focused practitioners to take more ownership over this period in a woman’s life course,” added Parikh. “I think that traditionally we’ve not thought of it as something within our wheelhouse, but increasingly with more at-risk women giving birth, we’re seeing a lot more adverse pregnancy outcomes, unfortunately. And we need to work closely with our [obstetrics] colleagues as well as with primary care doctors to ensure that these women have a good long-term trajectory.”

What Can Be Done?

Less solid than the literature linking APOs to cardiovascular risk, however, is the data on what to do about it. “Relatively few published studies have rigorously evaluated the utility of adding information about APOs to conventional CVD risk stratification,” the statement notes.

Also lacking are studies on how this association intersects with race/ethnicity, its authors point out. “Black and Asian women experience a higher proportion APOs, with more severe clinical presentation and worse outcomes, than White women,” they say, calling for more research on nonwhite women “to better understand and address these health disparities.”

Moreover, because most clinical trials of primary prevention didn’t collect pregnancy-history details, specific strategies are lacking. “It is unknown whether aspirin, statins, and metformin have a special role in prevention of CVD after APOs,” the authors say.

And, as pointed out by Parikh, thinking of this scenario as one that requires “primary prevention” may be off-target. With hypertensive disorders of pregnancy, such as preeclampsia, the link to increased CVD risk is particularly strong. “I wonder if a woman with that condition has actually experienced her first cardiovascular event, because it’s a pretty profound physiologic change,” she observed. “And if so, do we need to consider her for secondary prevention rather than primary prevention when we’re thinking about pharmacotherapy and the way we approach her [risk]?”

Clinicians can, despite the current knowledge gaps, encourage common-sense methods for risk reduction, such as a heart-healthy diet and physical activity, as well as breastfeeding.

Start Simple but Think Big

Parikh said that while awareness is growing in the cardiovascular community, it may not yet have translated into increased screening and more-aggressive prevention.

The simplest step, Parikh advised, is to “ask women their pregnancy and reproductive history” when assessing cardiovascular health. For her, this occurs while she’s taking notes during an office visit, in part thanks to “smart text” reminders embedded in the electronic medical record. This way, she said, “I can really consider those factors when I’m trying to understand whether I should recommend a statin, think about how aggressively to manage her risk factors, or screen her for cardiovascular disease.”

In an accompanying editorial, Eliza C. Miller, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), references the “golden hour” concept that’s common in acute conditions: a “critical time window for early recognition and treatment.”

“Many young women rarely (or never) seek medical attention outside of pregnancy. Thus, pregnancy and the postpartum period can be considered a ‘Golden Year’ in a woman’s life, offering a rare opportunity for clinicians to identify young women at risk and work with them to improve their cardiovascular health trajectories,” she writes.

Although she agrees that there’s “abundant, strong” evidence for a link between APOs and heightened CV risk, Miller also counters that “whether the APOs themselves are to blame from the pathophysiological standpoint, or whether APOs are simply an early marker of underlying cardiovascular risk, remains unclear.”

Regardless, too many women miss out on postpartum care, she stresses, “due to lack of insurance, childcare, or resources. Even more troubling, women with APOs have reported feeling traumatized by their childbirth-related encounters with doctors, leading them to avoid care afterwards. This holds particularly true for Black, Indigenous, and other women of color, LGBTQ+ people, non-English speakers, women with disabilities, and women with obesity,” many of whom have factors that put them at higher risk of having APOs in the first place.

Bolstering the “fourth trimester” with telehealth and home blood-pressure monitoring may help improves access, Miller suggests.

Similarly, the AHA statement advocates for more-seamless “transitions in care” after pregnancy.

“Delivery of healthcare is often segmented, and information about APOs has been the concern primarily of obstetricians only. However, the period after birth is a critical period for women to set the stage for the long-term health of themselves and of their families,” Parikh and colleagues stress.

In the bigger picture, “rigorous qualitative research is needed to understand how we can better support women who experience APOs both during and after the event,” Miller concludes, adding that it’s time for broad policy initiatives to capitalize on pregnancy “as a unique and fleeting opportunity for cardiovascular disease prevention in women.”

Policy measures like extension of coverage for postpartum care could enable better screening and provide time for counseling on CVD risk prevention. “Improved patient education is also necessary,” write Parikh et al. “Patients often do not know that having had a pregnancy complication might increase their future CVD risk,” they write, adding that physicians might also not recognize the potential impact of APOs.