Preeclampsia predicts risk for future hospitalizations for HFpEF
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Hypertensive disorders of pregnancy at the time of delivery were associated with a twofold greater risk for developing HF with preserved ejection fraction vs. deliveries uncomplicated by a hypertensive disorder, researchers reported.
“It is critical for clinicians to take a complete obstetric history, as obstetric complications represent important risk factors for future CVD,” Kathryn J. Lindley, MD, FACC, associate professor of medicine and of obstetrics and gynecology and director of the Washington University Center for Women’s Heart Disease, told Healio. “It is also extremely important for women with pregnancy complications such as preeclampsia to be provided with education on the long-term risks of their pregnancy complications, be screened for cardiometabolic risk factors and be transitioned into longitudinal care with a cardiologist or primary care physician. This is the first of many important steps toward better understanding the link between preeclampsia and HFpEF — much more important work needs to be done to better understand why this link exists, and what can be done to reduce this risk.”
The retrospective analysis utilized the New York and Florida state Healthcare Cost and Utilization Project State Inpatient Databases to identify women who gave birth from 2006 to 2014 (median follow-up, 72 months). The primary outcome was HFpEF hospitalization. Patients were followed from the time of delivery discharge to the primary outcome, death or completion of the study on Sept. 30, 2015. Secondary outcomes included any HF hospitalization or HF with reduced ejection fraction hospitalization.
Of the 2.5 million women who gave birth from 2006 to 2014, 5.1% had preeclampsia/eclampsia at the time of index delivery hospitalization.
Researchers reported that preeclampsia/eclampsia at the index hospitalization for delivery was independently associated with a more than twofold greater risk for HFpEF compared with women without preeclampsia/eclampsia (adjusted HR = 2.09; 95% CI, 1.8-2.44).
Median time to HFpEF onset was 32.2 months. Median age at diagnosis was 34 years.
Preeclampsia/eclampsia remained significantly associated with HFpEF after researchers excluded participants with gestational hypertension (aHR = 2.2; 95% CI, 1.97-2.46; P < .001).
Moreover, preeclampsia/eclampsia during the index hospitalization remained independently associated with risk for HFpEF when researchers included unspecified HF hospitalizations among HFpEF events (aHR = 1.91; 95% CI, 1.89-1.93) as well as the secondary outcomes (aHR = 2.09; 95% CI, 1.79-2.44).
“I’m not surprised by these results — there is a lot of overlap between preeclampsia and HFpEF,” Lindley told Healio. “Both are associated with inflammation and microvascular dysfunction. Preeclampsia is known to be associated with left ventricular hypertrophy and remodeling, a known precursor to HFpEF. Further, hypertension is a common risk factor for HFpEF. Thus, there are several physiologically plausible pathways through which preeclampsia may contribute to the female overrepresentation of HFpEF.”
Additional risk factors for HFpEF
Women with risk factors including chronic hypertension (aHR = 4.36; 95% CI, 3.18-5.98), diabetes (aHR = 5.35; 95% CI, 5.08-5.63) and Black race (aHR = 2.89; 95% CI, 2.51-3.32) also had elevated risk for HFpEF hospitalization, compared with women without those risk factors.
Additional factors associated with risk for HFpEF hospitalization included living in a rural area (aHR vs. metropolitan area = 1.59; 95% CI, 1.38-1.84), low income (aHR vs. highest income quartile = 1.22; 95% CI, 1.07-1.38) and Medicaid insurance (aHR vs. not on Medicaid = 1.41; 95% CI, 1.31-1.51), according to the results.
“Low-dose aspirin between around 12 weeks of gestation is associated with a substantial reduction in the incidence of hypertensive disorders of pregnancy,” Lindley told Healio. “Hypertensive disorders of pregnancy are also more common among women with preexisting CV risk factors such as diabetes, hypertension and obesity. Thus, improved access to care and preconception care, especially for the highest-risk women, is essential to improve CV health for women beginning pregnancy.”
A risk signal or directly causal
In a related editorial, Michael C. Honigberg, MD, MPP, cardiologist and researcher at Massachusetts General Hospital and instructor in medicine at Harvard Medical School, wrote that these findings “represent an opportunity for early implementation of primordial and primary prevention.
“Societies advise that women with preeclampsia undergo comprehensive cardiovascular risk factor assessment within 6 to 12 weeks postpartum and transition care to a primary care clinician for continued risk factor management.
“Whether preeclampsia merely represents a risk signal for conventional cardiovascular disease risk factors, reflects other unique disease mechanisms, and/or is also directly causal for future cardiovascular disease remains an unanswered question,” Honigberg wrote.
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For more information:
Kathryn J. Lindley, MD, FACC, can be reached at kathryn.lindley@wustl.edu.
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