AHA: 1-year period after pregnancy ‘critical time’ to assess long-term CVD risk
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Key takeaways:
- A new scientific statement outlines best practices to reduce CVD risk after adverse pregnancy outcomes such as preeclampsia.
- Clinicians should ask all women about pregnancy history and pregnancy complications.
Clinicians should screen and carefully follow women during the first year after delivery to reduce long-term CVD risk and optimize CV health after pregnancy, according to a new scientific statement from the American Heart Association.
The scientific statement, “Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk Following Adverse Pregnancy Outcomes,” published in Circulation, notes that pregnancy offers a “window of opportunity” to screen women for CVD risk, according to Jennifer Lewey, MD, MPH, director of the Penn Women’s Cardiovascular Health Program and co-director of the Pregnancy and Heart Disease Program at the University of Pennsylvania Perelman School of Medicine.
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“Pregnancy complications — preeclampsia, preterm birth and gestational diabetes — are increasingly common in the U.S. and research demonstrates that these complications are significant risk factors for heart disease and stroke,” Lewey told Healio. “Despite this, there is an underrecognition and underappreciation that these conditions are risk factors. Little is known on how to manage women after delivery to minimize their risk.”
The statement notes that the concept of the fourth trimester can be further extended to the first year after delivery as a “critical time to assess long-term CVD risk” and implement lifestyle changes to improve maternal CV health across the life course, with potential downstream impact on the CV health of offspring.
Risk with adverse pregnancy outcomes
Hypertensive disorders of pregnancy are the most prevalent CV conditions during pregnancy and bring significant risk; namely, a two- to fourfold higher risk for developing chronic hypertension between 2 to 7 years after delivery compared with normal BP.
“People who have hypertensive disorders of pregnancy are at significantly higher risk for developing chronic hypertension, and that risk of hypertension develops as soon as 1 year after delivery,” Lewey said during an interview. “It is so important to screen for this in reproductive age women.”
Similarly, gestational diabetes is associated with an eightfold risk for developing type 2 diabetes, whereas obesity increases risk for high BP during pregnancy, as well as gestational diabetes and CVD. Obesity is also associated with persistent high BP after pregnancy. Women with a history of one or more adverse pregnancy outcomes are more likely to experience an MI or stroke at younger ages compared with women with uncomplicated pregnancies, Lewey said, adding that race-based maternal health disparities continue to persist.
“Additionally, people also do not appreciate that CVD is the leading cause of maternal death among Black women,” Lewey told Healio. “Anything we can do to reduce these risks in a subsequent pregnancy is important.”
Better education needed
Lewey said clinicians must ask all women about pregnancy history and pregnancy complications when assessing their CV risk. The scientific statement includes a graphic for clinicians that offers guidance on steps to take with women during the early postpartum period (birth to 6 weeks), mid- to late-postpartum (6 weeks to 1 year), and long-term and interpregnancy (beyond 1 year). Steps include facilitating home BP monitoring via telemedicine for women with a hypertensive disorder of pregnancy during the postpartum period, for example, followed by close BP monitoring with medication adjustment as needed for the first year after delivery, and a CVD risk assessment with lifetime or 10-year risk calculators beyond 1 year, as well as contraception counseling for women with high-risk CVD.
“Individuals who have adverse pregnancy outcomes want and need better education about their CV risk,” Lewey told Healio. “In this statement, we provide a practical approach providers can use to educate patients, provide counseling and guide them on when to screen for risk factors. My hope is people will print out the table and keep it in their office, perhaps to use as a script for patients. This is for OB/GYNs, primary care physicians and cardiologists. It emphasizes the importance of making sure these women do not fall through the cracks.”
Research needed on optimal care after delivery
Interventions to mitigate short-term and long-term CVD risks that can come with adverse pregnancy outcomes, such as promotion of CV health based on the AHA Life’s Essential 8, are potentially useful but require more study, the statement notes. The authors wrote that more research is also needed on the implementation of policy-level changes that mitigate the adverse impact of social determinants of health, especially in resource-limited areas.
“We need to understand the risk and how to improve CV health in all populations, especially for those who experience disparities — Black women, Native American women, women living in low-income and rural areas,” Lewey said. “We need basic science and transitional research to understand the mechanisms linking adverse pregnancy outcomes and future CV risk. We need to better understand when to screen for heart disease and stroke, how to screen, and how to implement best strategies to reduce risk.”
“The statement is framed as a guide on how to achieve and strive for CV health,” Lewey told Healio. “We want to empower people to stay healthy. The changes you make now can have an effect on you and potentially your family.”
For more information:
Jennifer Lewey, MD, MPH, can be reached at jennifer.lewey@pennmedicine.upenn.edu.
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