OB/GYNs best positioned to assess heart disease risk after pregnancy

Key takeaways:

• Obstetricians play a critical role in CVD prevention for postpartum women with a hypertensive disorder of pregnancy.
• Risk calculators and remote blood pressure monitoring may improve outcomes after delivery.

Women diagnosed with a hypertensive disorder of pregnancy require careful management and follow-up after delivery, yet for many of these patients, the only provider they may see is their OB/GYN for a postpartum visit.

“A history of hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, is associated with an increased risk of developing both chronic hypertension and long-term CVD,” 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, and colleagues wrote in a narrative review published in Obstetrics & Gynecology. “Much of the future risk of CVD is thought to be mediated by the development of hypertension; therefore, screening for and treatment of hypertension remain critical to long-term health after hypertensive disorders of pregnancy.”

In an interview with Healio, Lewey said: “Because patients see their OB/GYN so frequently during pregnancy, OB/GYN clinicians are in an optimal position to assess CVD disease risk after delivery. Women and birthing people see their OBs as their primary care provider, but even if that is not the case, OB/GYNs can help assess for referring to other clinicians. They can also communicate with the patients about the importance of those care transitions and about what their risk may be for future pregnancies.”

Evaluating CVD risk for pregnant, postpartum people

The American College of Cardiology guideline on the primary prevention of CVD recommends use of an atherosclerotic CVD risk calculator to estimate 10-year risk for CVD based on factors such as age, cholesterol and BP levels.

Jennifer Lewey

“But as we discuss in the review, there are many limitations to using this calculator,” Lewey told Healio. “Primarily, we do not use that calculator for people who are younger than age 40 years. We recommend two other approaches OB/GYNs can take.”

One such approach is assessing CV health using the updated American Heart Association’s Life’s Essential 8 score, Lewey said. Metrics include health behaviors like diet, physical activity, nicotine exposure and sleep, and health factors like body weight, lipids, blood glucose and BP.

“I like this because it does not require a calculator, but it allows clinicians and patients to review the list of factors and then choose maybe one or two that someone can focus on to improve their long-term CV health,” Lewey told Healio. “That is a little kinder for people dealing with the stress of a newborn and other family dynamics at home. At different stages of their [postpartum] recovery, patients may want to focus on different things.”

The second alternate approach is the AHA’s new PREVENT equations, designed to predict long-term absolute risk tied to CV-kidney-metabolic syndrome.

“PREVENT also uses patient factors such as age, cholesterol level and BP, but it also factors in blood glucose level, protein in the urine and the environment where someone lives,” Lewey said. “We can also use this calculator for younger people to estimate 10-year and 30-year CVD risk.”

‘Small changes make a huge difference’

During the first weeks after delivery, clinicians must carefully manage BP to avoid severe hypertension, a risk factor for maternal morbidity and mortality, Lewey said.

“After the first 6 to 12 weeks, we want to assess whether someone progressed to chronic hypertension and think about screening for other risk factors such as high cholesterol and type 2 diabetes,” Lewey said. “What I try to communicate to other health care providers is that small changes in lifestyle can make a huge difference.”

“Lifestyle changes can lower both systolic and diastolic BPs and in combination can be as effective as antihypertensive medications,” Lewey and colleagues wrote in the review. Small changes can include reducing salt intake, incorporating more fruits, vegetables and whole grains into the diet and working toward a goal of 150 minutes per week of physical activity, as well as minimizing alcohol consumption and smoking cessation.

Best practices for remote BP monitoring

Remote BP monitoring at home, when performed correctly, can be the most accurate way to assess BP for a postpartum person, Lewey said.

“In nonpregnant populations, remote BP monitoring is important for confirming a hypertension diagnosis,” Lewey told Healio. “That also applies and is especially relevant for postpartum people. The added significance for postpartum people is during the early postpartum period, people are at risk for developing severe hypertension and maternal morbidity. It is difficult for people to come in for an in-person visit days after delivery. Using remote monitoring during those early weeks after delivery can help us keep an eye on people at home and make sure we are treating their BP. Patients also appreciate that extra set of eyes.”

Lewey recommended that clinicians steer patients toward a validated BP cuff, noting that many can be found on AMA website www.validatedBP.org. Many insurance companies now provide home BP kits at no cost for pregnant and postpartum people.

Lewey said clinicians should counsel patients to check BP at home during a time of day when they can sit still in a quiet area, with their arm resting on a table, for the most accurate measurement.

“We know that home BPs can be very accurate, especially when people follow these instructions,” Lewey said.

References:

• Arnett DK, et al. Circulation. 2019;doi:10.1161.CIR.0000000000000678.
• Khan SS, et al. Circulation. 2023;doi:10.1161/CIR.0000000000001191.

For more information:

Jennifer Lewey, MD, MPH, can be reached at jennifer.lewey@pennmedicine.upenn.edu; X (Twitter) @jennlewey.