Risk for heart failure in women after pregnancy underrecognized
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Key takeaways:
- Hypertensive disorders of pregnancy drive risk for CVD during and after delivery.
- Clinicians must reduce risk for hypertension during pregnancy to avoid risk for HF later in life.
PHILADELPHIA — Hypertensive disorders of pregnancy significantly increase risk for HF in women during pregnancy and later in life, yet many women never receive adequate preconception counseling or follow-up care, according to a speaker.
Hypertensive disorders of pregnancy are associated with long-term risk for diverse CVDs, ranging from CAD and aortic stenosis to mitral regurgitation and HF, with the greatest risks observed among women with recurrent pregnancy complications, Neha J. Pagidipati, MD, MPH, associate professor in the division of cardiology at Duke University School of Medicine and director of the Duke Cardiometabolic Prevention Clinic, said during a presentation at the Heart in Diabetes CME Conference.
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“It is becoming increasingly understood that HF in women is, unfortunately, common; by the age of 40 [years], women have a one in five risk for developing HF over the course of their lifetime,” Pagidipati said. “That risk increases as women age. By the time a women is aged 80 years, their risk for HF is higher than men. There are unique risk factors for HF in women, and at least some of those risk factors have to do with pregnancy, in particular hypertensive disorders of pregnancy.”
Compared with women with multiple births and no history of hypertension in pregnancy, those with preeclampsia have a twofold risk for developing HF with either reduced or preserved ejection fraction. Stark differences also persist by race; compared with white women, Black women with a hypertensive disorder of pregnancy have a twofold risk for developing HF within 5 years postpartum, Pagidipati said.
“Hypertensive disorders of pregnancy are not equal-opportunity offenders; this is getting more common among the women least able to access care,” Pagidipati said. “Overall prevalence is about 15%, but depending on where you look, up to one-quarter of pregnancies are affected by hypertensive disorders. It is more common among women who are Native American or Black, rural dwelling, poor and living in the South.”
Pregnancy as CV ‘stress test’
Hypertension is the greatest risk factor for HFpEF outside of pregnancy, so it should be no surprise that hypertension during pregnancy further compounds risk for HF during and after delivery, Pagidipati said. Data show preeclampsia is associated with increased left ventricular hypertrophy, arterial stiffness and echo features of diastolic dysfunction, as well as significant increases in microvascular dysfunction.
“Some might say we are uncovering a subset of women at increased risk for HF; she has undergone the ‘cardiac stress test’ of pregnancy and, unfortunately, she has failed,” Pagidipati said. “Alternatively, it might be that hypertensive disorders of pregnancy are part of the causal pathophysiology contributing to the development of HF. Hypertension itself is part of the causal pathway for at least half of these women. There is increased risk for CAD, there are direct cardiac changes and all these inflammatory changes.”
Preventing hypertension in pregnancy and associated HF
To prevent HF associated with hypertensive disorders of pregnancy, clinicians must work to prevent hypertensive disorders of pregnancy, Pagidipati said. That means, ideally, preconception counseling about optimizing lifestyle, weight, BP and managing diabetes. Clinicians should also educate women about their future risks and the importance of follow-up.
“One-third of women after a hypertensive disorder of pregnancy have chronic hypertension 21 years later, but only half of those women had received a formal diagnosis,” Pagidipati said. “Only 9% of internists and 38% of obstetricians provide counseling about CV risk reduction following delivery in women with a history of preeclampsia, mostly due to lack of awareness of future risk.”
Also important is to understand how to treat a woman who is pregnant and at high risk for developing hypertension, Pagidipati said. Data from the ASPREE trial show treatment with low-dose aspirin in women at high risk for preterm preeclampsia resulted in a lower incidence of this diagnosis than placebo; the OR for preterm preeclampsia in the aspirin group was 0.38 (95% CI, 0.2-0.74; P = .004).
The American College of Obstetrics and Gynecology also recommends that women at high risk for preeclampsia initiate low-dose aspirin therapy.
After delivery, postpartum transitional clinics have shown to be a promising model to provide follow-up care for women and reduce CV risk, Pagidipati said.
“There is a clear link between hypertension in pregnancy and HF, and these they are going after our most vulnerable patients,” Pagidipati said. “When we have a woman with a hypertensive disorder of pregnancy, we have an indication very early in that woman’s life that she is at risk. It is incumbent upon us to make sure that we educate her about that, and that we do not lose her in the health system.”
Reference:
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Pagidipati NJ, et al. Session 1 – Heart Disease in Women. Presented at: Heart in Diabetes CME Conference; June 9-11, 2023; Philadelphia.
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