Lifestyle Changes Can Curb CVD Risk After Adverse Pregnancy Outcomes

Women with a history of adverse pregnancy outcomes (APOs), including gestational hypertension, gestational diabetes, or preeclampsia, can reduce their long-term risk of cardiovascular disease by maintaining optimal heart health, according to new data.

The researchers measured cardiovascular health using the American Heart Association (AHA)’s Life’s Essential 8 (LE8) score, which ranges from 0-100 based on diet, physical activity, smoking cessation, sleep, weight, cholesterol, blood sugar, and blood pressure. They found that women with a history of APOs who achieved or maintained high heart health (scores > 76) after pregnancy were at a similar risk for CVD down the line as those with good cardiovascular health who never had APOs.

“We have known for a long time that [APOs] are bad for birth outcomes, . . . but what we are figuring out is that it seems that women with these conditions also have a higher likelihood of developing cardiovascular disease later on in life, including up to several decades later,” Frank Qian, MD (Boston Medical Center, MA), who presented the findings at the AHA’s Epidemiology and Prevention│Lifestyle and Cardiometabolic Health Scientific Sessions 2024 last week, told TCTMD. “What I think was not well known prior to our study was how much of this risk is potentially modifiable.”

Josephine Chou, MD (University of Colorado Hospital, Aurora), who commented on this study for TCTMD, said the findings have implications for both cardiologists and internists. “We are often not very good at asking about pregnancy-related complications; it is not what we are trained in, but it is low-hanging fruit for us to ask about,” she said. “It opens the door to the conversation with the patient about starting cardiovascular risk assessment and prevention earlier.”

Lifestyle a Powerful Influence

For the study, Qian and colleagues included 2,263 patients from the UK Biobank with a prior diagnosis of APOs (defined as hypertensive disorders of pregnancy, gestational diabetes, placental abruption, small for gestational age, or preterm birth) as well as a comparator group of 107,260 parous women without a history of APOs. None had a history of CVD at baseline.

Over a mean 13.5 years, the APO group reported 197 incident CVD events. The incidence of CVD events was indirectly related to LE8 score with those scoring in the highest tertile (< 76) at a lower risk of total CVD (HR 0.43; 95% CI 0.29-0.65), coronary heart disease (HR 0.31; 95% CI 0.17-0.56), and atrial fibrillation (HR 0.46; 95% CI 0.23-0.91) compared with those scoring in the lowest tertile (< 67).

Moreover, the researchers observed a significant interaction between APO history, LE8 score, and incident CVD in two models, the first adjusted for age and race/ethnicity and the second additionally adjusted for alcohol use, education, employment status, Townsend Deprivation Index, family history of CVD, age at menarche, and gravidity.

Incident CVD Risk by APO History and LE8 Score: HR (95% CI)

Finally, compared with women without an APO history with an LE8 score above 76, those with a history of APO who also maintained a high LE8 score were at similarly low risk for incident CVD (HR 0.95; 95% CI 0.63-1.43), but this was not the case for those with intermediate and low LE8 scores.

We should really do a more detailed assessment of cardiovascular health in this population. Frank Qian

There were some striking differences when the researchers dug into the different components of the LE8 scores, Qian reported. “These women with adverse pregnancy outcomes were less likely to smoke and actually, on average, had better blood lipids,” he said. “But the key drivers—and I think this may play into how we might in the clinical setting improve the cardiovascular outcomes in these populations—is their diets seem to be worse. They had a much higher prevalence of suboptimal blood glucose levels and their weight was on average a little bit higher.”

These factors are “levers we can pull on, ideally even before these women become pregnant, but certainly after they develop these adverse pregnancy outcomes,” Qian urged. “We want to target those specific risk factors more extensively.”

He called on all cardiologists to routinely ask patients about APOs, even if the pregnancies occurred decades before. Secondly, for those with a history of APOs, Qian said “we should really do a more detailed assessment of cardiovascular health in this population,” so that any modifiable factors can be addressed.

Going forward, Qian said he would like to see more randomized research done looking at the CVD impact of lifestyle modification on patients with a history of APOs as well as studies exploring the mechanism linking these conditions. “It seems like inflammation and endothelial dysfunction is playing a pretty key role here,” he said.

Chou said she would also like to see more data on how race and ethnicity might come into play here. “Black women and Native American women shoulder a higher burden of pregnancy related mortality and morbidity and are at higher risk for developing hypertensive disorders of pregnancy and lifelong cardiovascular disease,” she said. “I would like to see if lifestyle modification for those patients gives us a greater risk reduction as opposed to patients who have a lower risk from a racial and ethnicity perspective.”