Remote blood pressure intervention in first few weeks after pregnancy yields long-term benefit
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Key takeaways:
- Hypertensive disorders of pregnancy impact 10% of women worldwide.
- A remote intervention of self-monitoring and physician-guided titration of medication improved 24-hour BP in the first 9 months postpartum.
PHILADELPHIA — In a new trial, remote self-monitoring of blood pressure and physician-guided titration of medication after a hypertensive pregnancy lowered BP during the first 9 months postpartum more than usual care, a speaker reported.
“The postpartum period appears to be a critical window to reduce longer-term risk. This is the first randomized trial evidence to show blood pressure interventions in the first few weeks after pregnancy can have long-term benefits,” Jamie Kitt, DPhil, consultant cardiologist, internal medicine physician and postdoctoral research fellow in the division of cardiovascular medicine at University of Oxford, U.K., said during a late-breaking science presentation at the American Heart Association Scientific Sessions.
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Benefits of remote intervention
The POP-HT trial was conducted at a single hospital in the United Kingdom and enrolled participants following a pregnancy complicated by preeclampsia (60%) or gestational hypertension (40%) who required continued antihypertension medication after childbirth. Researchers randomly assigned 220 participants (mean age, 32.6 years) to a remote BP control intervention immediately after delivery or usual postpartum care, which involved an office visit with a family physician or midwife 5 to 10 days after delivery and another visit 6 to 8 weeks later.
The intervention group received a wireless BP monitor (Omron Evolv, Omron Healthcare Europe) with instructions to send daily BP readings via a smartphone app. The app would then send the participant notifications based on their BP levels to repeat a reading or contact their doctor if a medication change was warranted. Physicians then advised participants remotely on how to adjust their medication to reach their target BP of less than 140/90 mm Hg.
The primary outcome of 24-hour mean diastolic BP at 9 months postpartum was 71.2 mm Hg in the intervention group compared with 76.6 mm Hg in the usual care group, for a between-group difference of –5.8 mm Hg (P < .001), according to the results.
The researchers observed a similar trend for systolic BP. At 9 months, 24-hour mean systolic BP was 114 mm Hg in the intervention group compared with 120.3 mm Hg in the usual care group, for a between-group difference of –6.51 mm Hg (P < .001).
“A 5 mm Hg improvement in blood pressure, if maintained longer term, would result in an approximately 20% reduction in lifetime cardiovascular risk,” Kitt said.
Mean clinic systolic and diastolic BP were also lower in the intervention group.
Forty-one hospitalizations occurred in the first 14 days after initial discharge; 37 were BP-related postnatal admissions, with 29 in the usual care group and eight in the intervention group.
Participants in each group were prescribed similar antihypertensive therapies, including use of enalapril, nifedipine and labetalol. Median duration of treatment in the intervention group was 39 days. At 6 weeks postpartum, 30% of participants in each group were still taking antihypertensive medication, which decreased to 12% by the final visit at 6 to 9 months postpartum.
There were no significant differences in lifestyle or nonpharmacological factors, breastfeeding, use of hormonal contraception or quality of life scores between the two groups.
The results were simultaneously published in JAMA.
Researchers also looked at the impact of this intervention on cardiac remodeling in a substudy that was simultaneously published in Circulation. The substudy showed significant increases in left and right ventricular systolic function and improvements in LV diastolic function in the intervention group by 9 months postpartum, as assessed by transthoracic echocardiogram and cardiac MRI.
‘Need for a paradigm shift’
Hypertensive disorders of pregnancy impact one in 10 women worldwide. Moreover, one-third of women after a hypertensive pregnancy presents with chronic hypertension within a decade, Kitt said during the presentation.
“Improving postpartum blood pressure control impacts short- to medium-term blood pressure control that persists after medications are stopped,” Kitt said. “This trial identifies a potential need for a paradigm shift in the way women affected by hypertensive pregnancy are managed postnatally,” Kitt said.
References:
- Kitt J, et al. JAMA. 2023;doi:10.1001/jama.2023.21523.
- Kitt J, et al. Circulation. 2023;doi:10.1161/CIRCULATIONAHA.123.067597.
Perspective
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The POP-HT trial looked at women with hypertensive pregnancies who were randomly assigned to usual care vs. remote self-management of their BP after delivery, with the focus on having the patients manage their BP. The results clearly showed that in patients assigned the remote BP intervention vs. usual care, there were superior reductions in diastolic as well as systolic BP in the first 9 months postpartum. There were also fewer complications, which was significant. While a small study, it also showed some benefits in surrogate markers like LV mass.
The reality is that we need new strategies for postpartum hypertension. This is an area that has not been well treated. In patients with postpartum hypertension, early intervention is clearly important. Maybe this kind of strategy of empowering the patients to do self-monitoring might be more effective and can help bridge some of the current gaps in postpartum hypertension management. There are potential disadvantages of such a strategy to think about, like access, adherence and the digital divide. Overall, this is a hypothesis-generating study.
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Kitt J, et al. LBS.04. Using drugs, diet and delivery to optimize hypertension outcomes. Presented at: American Heart Association Scientific Sessions; Nov. 11-13, 2023; Philadelphia.
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