Sizeable Minority of Pregnant Women Have CVD, US Data Show

Over the past decade, one in nine women hospitalized during pregnancy in the United States had some form of cardiovascular disease. But while CVD is on the rise in this unique population—and linked to higher rates of mortality and other adverse outcomes, plus a greater risk of returning to the hospital postpartum—there are some hints of good news.

The results, culled from a data set of around 39 million women, were presented as a poster at the American Heart Association (AHA) 2022 Scientific Sessions and simultaneously published in the European Heart Journal.

Lead author Monil Majmundar, MD (University of Kansas Medical Center, Kansas City), told TCTMD the lack of contemporary evidence in this area inspired them to conduct their study. Importantly, the researchers looked at a spectrum of CVD types, from hypertensive disorders to heart failure, arrythmias, aortic dissection, structural heart disease, stroke/TIA, and ischemic heart disease, among others.

He suggested that the rise in CVD seen here may not be what it seems at first glance. “We definitely know that newer guidelines are coming out on pregnancy and the definitions [for CVD] are also changing, so that also contributes to the increasing prevalence,” Majmundar explained.

Their study found that, amid growing recognition, all-cause mortality among pregnant women with CVD has started to decrease, Ankur Kalra, MD (Franciscan Health, Lafayette, IN), the study’s senior author, pointed out to TCTMD.

Thus, greater awareness about heart disease and pregnancy, as evidenced by the growth in cardio-obstetrics, a cross-disciplinary specialty, could be having a positive impact by getting these patients the diagnoses and treatments they need. “Kudos to multidisciplinary teams, which I think are only going to become more commonplace,” Kalra added.

He said that these positive shifts in the care of pregnant women may be reflective of what’s happening on a broader scale for female patients. “I don’t think the prevalence of disease is increasing per se in women. I think we’ve just become more sensitive to diagnosing heart disease in women,” thanks to campaigns like the AHA’s Go Red for Women, Kalra noted.

Hypertensive Disorders Most Common

Majmundar, Kalra, and colleagues used the Nationwide Readmission Database to identify around 39 million pregnant patients who were hospitalized for any reason between 2010 and 2019. Among them, 4.4 million (11.3%) had some form of CVD. Mean age was slightly older than 28 years, and this was nearly identical in patients with and without CVD. Nearly all of the hospital admissions (88%) were for delivery.

Age-adjusted CVD prevalence rose over the course of the decade: from 9.2% in 2010 to 14.8% in 2019 (P < 0.001). Noncardiac comorbidities also increased over that time.

Overall, CVD was seen in 1,125 out of every 10,000 pregnant women studied. The incidence per 10,000 for various types of CVD included: hypertensive disorder of pregnancy (1,069), valvular heart disease (25.7), cardiomyopathy (15.3), arrhythmia (14.8), heart failure (13.9), congenital heart disease (8.2), pulmonary hypertension (5.4), ischemic heart disease (4.9), stroke/TIA (3.3), cardiac arrest (1.6), and aortic dissection (0.1).

Each of these CVD categories increased over the course of the study apart from valvular heart disease, which decreased from 35.0 to 22.5 per 10,000 between 2010 and 2019 (P < 0.001).

In-hospital all-cause mortality, adjusted for age, amounted to 8.2 deaths per 10,000 hospitalized pregnant women overall, decreasing from 8.1 to 6.5 per 10,000 between 2010 and 2019 (P < 0.001). The highest death rates were seen in those who experienced cardiac arrest (38.2%), dissection (7.8%), and stroke/TIA (4.5%), whereas the lowest death rates accompanied hypertensive disorder of pregnancy (0.02%), congenital heart disease (0.15%), and valvular heart disease (0.20%).

Compared with patients without CVD, those with CVD faced much higher risk of dying (OR 15.51; 95% CI 13.22-18.20). CVD also was linked to increases in 6-week postpartum readmission (OR 1.97; 95% CI 1.95-1.99), MI (OR 3.04; 95% CI 2.57-3.59), and stroke (OR 2.66; 95% CI 2.41-2.94).

In addition to improvements in the care of women with existing heart disease, primary prevention is key, said Majmundar. He drew attention to the tighter targets set for BP control by recent US and European hypertension guidelines as especially important, given that hypertensive disorders of pregnancy—including gestational hypertension, preeclampsia, and eclampsia—were seen so commonly in their data set. “I feel that if we can control the hypertension [at the start of] the pregnancy, we can prevent a lot of things,” he said, stressing that “every effort should be made” to keep systolic BP levels below 130 mm Hg.

Kalra agreed that for primary care physicians and obstetricians it’s crucial to pay attention to hypertension in this population. The two areas most in need of active clinical investigation in relation to pregnancy, he added, are acute coronary syndromes and heart failure.