Preeclampsia raises risks for future myocardial infarction, ischemic stroke
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The odds of myocardial infarction and ischemic stroke are greater among women with vs. without preeclampsia for more than 20 years after pregnancy, according to findings published in the European Journal of Preventive Cardiology.
“The high risk of cardiovascular disease after preeclampsia manifests at young ages and early after delivery,” Sara Hallum, PhD, who was a guest researcher in the department of public health at the University of Copenhagen in Denmark during the study, said in a press release. “This indicates that interventions to prevent heart attacks and strokes in affected women cannot wait until middle age when they become eligible for conventional cardiovascular screening programs.”
Hallum and colleagues used linked data from multiple Danish registers to identify 1,157,666 women who had a live or stillbirth from 1978 to 2017 who did not have any circulatory system disorders before their first pregnancy.
For the primary outcome, the researchers calculated the risks for acute myocardial infarction (MI) and ischemic stroke among women with and without a diagnosis of preeclampsia, eclampsia or HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome in the month before delivery or within 7 days postpartum. Each woman was followed until the primary outcome occurred, they died or emigrated, the end of the study period was reached or 20 years had passed since the first delivery.
In total, there were 64,357 pregnancies complicated by preeclampsia among 58,120 women. Within 20 years of their first pregnancy, 3,089 women had acute MI, and 5,119 women had ischemic stroke as their first ischemic event.
The 20-year incidence of the composite endpoint of acute MI or ischemic stroke was 1.84% (95% CI, 1.68-2) among women younger than 35 years who had preeclampsia and 0.96% (95% CI, 0.93-0.98) among women younger than 35 years without preeclampsia. Among women older than 35 years at delivery, the composite endpoint incidence was 4.13% (95% CI, 3.2-5.06) with preeclampsia and 2.13% (95% CI, 1.98-2.28) without preeclampsia.
Acute MI
Compared with no preeclampsia, preterm preeclampsia (HR = 2.84; 95% CI, 2.44-3.3) and term preeclampsia (HR = 1.67; 95% CI, 1.53-1.82) were associated with greater odds for acute MI.
Associations were strongest among younger women and women whose most recent delivery was 10 or fewer years prior; the risk was four times higher among women with vs. without preeclampsia 10 years after delivery (HR = 4.16; 95% CI, 3.16-5.49). Twenty years after delivery, the risk remained two times higher among women with vs. without preeclampsia (HR = 1.98; 95% CI, 1.49-2.64).
Ischemic stroke
Similar to the association with acute MI, preeclampsia increased the risk for ischemic stroke 10 years after delivery (HR = 2.59; 95% CI, 2.04-3.28). At 20 years after delivery, women with preeclampsia maintained a higher risk for ischemic stroke (HR = 1.96; 95% CI, 1.55-2.48).
Preterm preeclampsia specifically had the strongest association with ischemic stroke (HR = 2.2; 95% CI, 1.92-2.51).
“Women are often in contact with the health care system during and immediately after pregnancy, providing a window of opportunity to identify those at increased risk of cardiovascular disease,” Hallum said in the release. “Prevention should start within a decade of delivery, for example by treating high blood pressure and informing women about risk factors for heart disease such as smoking and inactivity.”
References:
- Hallum S, et al. Eur J Prev Cardiol. 2023;doi:10.1093/eurjpc/zwad003.
- Pre-eclampsia linked with four-fold higher risk of heart attack in decade after delivery. www.escardio.org/The-ESC/Press-Office/Press-releases/pre-eclampsia-linked-with-four-fold-higher-risk-of-heart-attack-in-decade-after. Published Jan. 26, 2023. Accessed Jan. 30, 2023.
Perspective
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Erin D. Michos, MD, MHS, FACC, FAHA, FASE, FASPC
Pregnancy — nature’s free stress test — is a window into maternal cardiovascular health. Hypertensive disorders of pregnancy remain one of the leading causes of maternal morbidity and mortality, but risks do not end at delivery. There has been increasing recognition of the long-term vascular risks associated with an adverse pregnancy outcome.
The 2019 American College of Cardiology/American Heart Association Guideline for Prevention of Cardiovascular Disease has identified a history of adverse pregnancy outcomes such as preeclampsia as a “risk-enhancing” factor that would place women into a high-risk category, favoring more intensive preventive efforts, such as statin therapy for those otherwise at borderline or intermediate estimated atherosclerotic cardiovascular disease (ASCVD) risk. However, the ascertainment of a comprehensive reproductive history is infrequently performed in clinical practice. Unless patients are asked about their pregnancy histories, this “red flag” of risk may not be fully captured by traditional risk factors alone, resulting in missed opportunities to deliver preventive interventions.
In this latest study published in the European Journal of Preventive Cardiology, Hallum and colleagues examined a large national registry from Denmark of over 1 million parous women — 2.9% with a history of preeclampsia — and followed them for 2 decades for future ASCVD events. The excess vascular risks associated with preeclampsia were striking. Women with a history of preeclampsia had a 4-fold risk for acute MI and risks for ischemic stroke of up to 3-fold, compared with women with no history of preeclampsia, within 10 years postpartum. Even 20 years after delivery, there remained doubly higher rates of acute MI and stroke. The relative risks associated with preeclampsia were greatest among women 30 to 39 years with an up to 5-fold increased risk of acute MI compared with women the same age without preeclampsia.
The study was conducted from 1978 to 2017. The prevalence of preeclampsia was 2.9% in this cohort, but prevalence of preeclampsia has been increasing in the U.S. to about 5% to 8%, given increased prevalence of prepregnancy comorbidities, such as chronic hypertension and obesity, and also due to better diagnosis of preeclampsia. This current study was also conducted in Denmark, so included predominantly white women, but we know there are significant racial/ethnic disparities with Black women having disproportionately higher rates of preeclampsia than white women, as well as higher rates of maternal mortality.
To prevent long-term cardiovascular complications in mothers and their offspring, it is important to think about a life course approach to prevention, with strategies to improve cardiovascular health of reproductive-aged women pre-pregnancy, during pregnancy, inter-pregnancy and long term. Women with a history of preeclampsia should be educated about both their short -erm and long-term vascular risks. It is important that they do not get lost to follow-up after delivery. A seamless handoff from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risks. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring and behavioral health coaches might be potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness.
That these women are at elevated cardiovascular risk, even at younger ages, highlights the importance of taking a comprehensive reproductive history. The identification of an adverse pregnancy outcome is a “red flag” that warrants more intensive preventive efforts including lifestyle management and/or pharmacotherapy where appropriate. The time is now to start including reproductive history in risk assessment as a vital sign of women’s vascular health.
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