Chapters Transcript Long Term Implications of Pre-eclampsia and Gestational Hypertension Course: Cardio-Obstetrics: A Team-Based Approach to Optimizing Heart Health in Pregnancy and Beyond Next, I'd like to introduce to everybody, uh, Doctor Anais Hausfodder. Uh, she's a clinical instructor here at NYU and has developed a pretty incredible expertise in the long term after effects of preeclampsia and what it means for the future for somebody's life when they develop this disease that is increasingly common in pregnancy. So, uh, we welcome Anais and look forward to hearing from you. Great. Thank you so much. I'm thrilled to be here to talk to you today about the long-term implications of preeclampsia and gestational hypertension. So my goals for this talk, I'll be reviewing the evidence of cardiovascular risk after hypertensive disorders of pregnancy. I'll be providing some insights into mechanisms of cardiovascular disease after HDP. I'll be reviewing cardiovascular risk prediction after HDP, um, as well as discussing some management after HDP. So as many in this audience already know, it's really important to consider that biologically female patients have really unique cardiovascular risk factors that span the life course and in particular pregnancy offers this unique window of opportunity to assess the patient's cardiovascular risk. We now understand that these adverse pregnancy outcomes, including preeclampsia. Gestational diabetes, gestational hypertension, preterm birth, and delivery of a small for gestational age infant really increase a patient's risk and remain lifelong cardiovascular risk factors. Doctor Penfield already reviewed how we define hypertensive disorders of pregnancy, but I just wanted to remind everyone that this is really a spectrum of disorders that spans um a more mild form being gestational hypertension, all the way through to a more severe form being preeclampsia and HHELP syndrome, which are really multi-organ system um dysfunction. In 2018, the American College of Cardiology and the American Heart Association, um, acknowledged that pregnancy complications are risk enhancers, including preeclampsia, and this was added to our guidelines, um, when considering who is at high risk of atherosclerotic heart disease and who should be initiated on a statin. So what's the risk we're actually talking about here? This figure comes from a really nice review paper that illustrates how to start underlying prenatal cardiovascular risk factors such as obesity, diabetes, and hypertension, increase an individual's risk for the development of hypertensive disorders of pregnancy. And we're seeing this more and more commonly. In addition, we see that hypertensive disorders can often co-occur with other adverse pregnancy and fetal outcomes, like small for gestational age infants and preterm delivery. And when these do co-occur, the risk is even higher. We see that HDP increases the risk of many different cardiovascular outcomes, including chronic hypertension, coronary artery disease, stroke, heart failure, and cardiovascular mortality. And this figure nicely illustrates that the risk starts as early as the decade after pregnancy. So this is really an important time to initiate preventative strategies. The most significant risk in the immediate term after HDP is the development of chronic hypertension. This is generally defined as persistent hypertension by 6 months postpartum. In a large pregnancy cohort of 500,000 patients in the UK, they compared the rates of new onset hypertension in those with versus without HDP history, and they found that rates of post-pregnancy hypertension were up to 25 times higher in those with HDP history within the first year postpartum. The risk was 10 times higher in 1 to 5 years postpartum, so this risk really accumulates early. Um, in the new mom to be cohort, which is a large, um, pregnancy cohort of over 4000 women, they found that 39.2% developed chronic hypertension after HDP within 3 years. Another study found that having higher BMI or obesity postpartum conferred excess risk for the development of chronic hypertension. So this is another important target for intervention. We also see evidence of early atherosclerosis among individuals with prior HDP. This is a really nice study from um Sweden of 700 women aged 40 to 55, who had a history of preeclampsia, and they compared them to 700 age and parity match controls. And all patients underwent coronary CTA. And they found that even after adjusting for underlying cardiovascular risk factors, women with a history of preeclampsia had 1.4 times higher odds of any atherosclerosis on coronary CT compared to controls. So this suggests to me that these patients have accelerated premature atherosclerosis, but also that the development of atherosclerosis is mediated by a mechanism other than the increase in cardiovascular risk factors. In a recent study out of UPMC that Doctor Reynolds and I were lucky enough to co-author, um, 391 women who presented with premature myocardial infarction, um, were studied. And they found that those, among those women who had premature myocardial infarction, Those who had a history of adverse pregnancy outcomes, particularly those who had preeclampsia, tended to present even earlier with their myocardial infarction. This was true also for gestational diabetes and hypertensive disorders of pregnancy, but preeclampsia, the patients with preeclampsia presented the earliest, um, a median time of 17 years after, uh, pregnancy. Most concerning, we see that women who have HDP may be at increased risk of premature death. In this study of 88,000 women from the nurses Health Study who were followed for an average of 28 years, 14% had a history of HDP, and they found that compared to no HDP controls, those with either gestational hypertension or preeclampsia had 30% higher risk of premature mortality, which they defined as uh mortality at an age less than 70. And they found that the hazard ratio was strongest for cardiovascular disease related death, and this was largely driven by women who experienced HDP in multiple pregnancies or those who reported delivery of a low birth weight infant. So the takeaway here is that hypertensive disorders of pregnancy promote this idea of accelerated cardiovascular aging. Proposed mechanisms for the increased cardiovascular risk after HDP are really multifaceted. We know, as I mentioned earlier, that many patients go into pregnancy with an increased burden of these cardiovascular risk factors like hypertension, obesity, hyperlipidemia, that put them at risk for HDP. Then, as Doctor Penfield talked about earlier, there's this inciting event where there is defective maturation of the placenta, which leads to this cascade of events including the release of antiangiogenic factors and pro-inflammatory factors that then result in HDP. Many studies have shown that even after HDP, there's um residual endothelial dysfunction. Residual uh pro-inflammatory uh cascades, abnormal cardiac mechanics, increase in arterial stiffness. And in parallel, these patients also are more likely to have adverse lifestyle factors and have lower cardiovascular health in general. So, in combination, all of these increase risk. Studies have shown that prenatal cardiovascular risk factors mediate about 50% of the excess cardiovascular risk. And the development of chronic hypertension after HDP mediates up to 60% of the excess risk of coronary artery disease and about 50% of the excess risk of heart failure. So there's still kind of, there's 50% risk um that's driven by a mechanism other than these risk factors. So how do we actually predict who after our HD HDP is at greatest risk? Many studies have attempted to include HDP history into existing risk prediction models like the Framingham score, and they found that this does not really improve discrimination and risk prediction or risk reclassification. And this is felt to be due to the fact that the incremental information provided by an HDP history may already be captured by the fact that they have this increase in cardiovascular risk factors. It's likely that this, that HDPS history is most important for our younger patients. Um, and when assessing risk in these patients, it's recommended to use 30-year or lifetime risk calculators rather than our standard 10 year ASCBD calculator. So how do we actually manage these patients? So, as I mentioned before, in the first year, the risk, the highest risk is really the the development of chronic hypertension. And the rate of progression to chronic hypertension is quite high. Um, one study using ambulatory and in office blood pressure has found that up to 42% of patients who had preeclampsia with severe features had persistent hypertension. There's a big role here for remote blood pressure monitoring, um, particularly because the same group found that, um, 17% of cases actually had mass hypertension, whereby they had normal-looking blood pressures in the office, but on average, their blood pressures at home were considered in the hypertensive range. And they found that those who had obesity, black race, and a higher severity of HDP were at highest risk. Other studies suggest that remote blood pressure monitoring in the 1st 6 months can reduce the duration of anti-hypertensive therapy and can reduce the risk of chronic hypertension. So it's really important when assessing a patient's risk or thinking about prevention after HDP to acknowledge that there are many barriers that these patients face to risk reduction care. Um, for one, few healthcare providers carry out postpartum cardiovascular risk counseling or screening. This might be due to a lack of physician awareness of the connection between HDP and cardiovascular disease, or just um not having kind of the optimal opportunity to counsel these patients. But either way, it results in a lack of patient education about that risk. It's also unclear when is the right time and venue to discuss this with the patient. It's so when they have just delivered their baby. They're delirious, they're new moms, you know, is that the right time to tell them or do you wait until 6 weeks postpartum? Um, however, up to 40% of patients don't attend their postpartum visits. So, um, it's challenging to know when is the right time. Um, also, implementing recommended interventions for risk reduction is very challenging in this population. It's challenging in all of our cardiovascular patients. But, um, anyone who's ever been a mom to a newborn knows that you are kind of the last thing to be taken care of. Um, so it's hard to kind of tell these patients that they should, you know, exercise 5 times a week and eat healthy. Um, as I mentioned, remote blood pressure monitoring is a really promising method. Of um improving adherence, but this is often not reimbursed by insurance, so that can be a barrier. Um, and also there's poor follow-up, as I mentioned, after birth. This can be in part due to socioeconomic reasons, childcare responsibilities, um, and also, a lot of patients who have had preeclampsia have very high rates of post-traumatic stress disorder associated with their labor, um, and this can decrease follow-up. So what is um cardiovascular prevention care after HDP actually look like? I think this is still an evolving field, but in general, it's recommended um that we screen these patients at least 1 year postpartum, but ideally up to 3 months postpartum. Um, it's, it's recommended to check a blood pressure, a weight, screen them for diabetes, screen their cholesterol. Um, as Doctor Amita mentioned, pregnancy itself can alter cholesterol levels. So we think that potentially 3 months postpartum is the earliest. We should be checking cholesterol. Um, home blood pressure monitoring, as I mentioned, for those who go into pregnancy and are discovered to have chronic hypertension, consideration of secondary hypertension workups, given all these patients are very young, and then in some individual patients, potentially a role for calcium scoring. Education is um really the cornerstone of what we're doing. So we talked to these patients about how to optimize their cardiovascular risk. And uh with my patients, I use the model of life's Essential 8. And I try to really tailor each component of the Life's essential 8 to kind of a new mom and the type of lifestyle that they are living. Um, but we also want to make sure to do preconception counseling, cause a lot of these patients might be planning a subsequent pregnancy, and it's never too early to make sure they're aware they need to be on low dose aspirin in the next pregnancy, um, and also that potentially spacing out the interpregnancy interval might decrease their risk. And in particular, optimizing their cardiovascular health prior to going into a subsequent pregnancy will also lower that risk. Um, in terms of management, referral to a nutritionist can be very helpful for some of these patients. As I mentioned, obesity, um, is a huge risk factor for a lot of these patients for the development of chronic hypertension. And then there's still a lot of kind of therapies that we need further research on. For example, postpartum aspirin. There are some clinical trials about that. Um, postpartum statins. Doctor Doctor Meta kind of touched on this, but a lot of these patients are, might have indications for statins, but are planning on subsequent pregnancies. So how do you kind of decide whether it's the right time to start a statin? And then potentially a role for kind of newer obesity medications like the GLP ones in the patients who are prone to obesity. Um, so, in summary, hypertensive disorders of pregnancy are really lifelong risk factors that are associated with increased risk of cardiovascular disease, in particular, chronic hypertension, premature atherosclerosis, myocardial infarction, and cardiovascular death. The risk of chronic hypertension is highest in the early years and is a key mediator of other cardiovascular sequelae. The mechanisms of cardiovascular disease after HDP are diverse. Um, and they include a combination of persistent endothelial dysfunction, abnormal cardiac mechanics, and suboptimal cardiovascular health. We need better tools to predict an individual patient's risk after HDP, and the management after HDP consists of blood pressure, blood pressure monitoring, cardiovascular risk screening, and education. So here at NYU we have started this um postpartum cardiovascular health clinic, acknowledging everything I just said that these patients are at high risk, and we really wanna get them in early after pregnancy to optimize their cardiovascular health and reduce their cardiovascular risk. Um, so this was really the brainchild of Doctor Jeffrey Burger, um, who is the head of our cardiovascular prevention center. And really our goal is to reduce risk as much as possible and identify any modifiable risk factors that can be optimized for these patients. Um, we're a multidisciplinary team. We work closely with MFM. Doctor Penfield is our co-director, and, um, Swathy Bollani is one of our great um PAs who's gonna start seeing these patients as well. Our, um, program has kind of two tracks for referrals. We see patients in the immediate postpartum period who need kind of active blood pressure management and close monitoring of their blood pressure and titration of blood pressure medications. And then, um, we also see non-urgent, um, kind of cardiovascular health optimization patients. Um, we tend to see them at 3 months postpartum. And assess their cardiovascular risk and then kind of follow up is determined based on how high their risk is. And we hope this will be both an opportunity to really improve care for our patients, but also a rich opportunity for research, which is much needed in, um in this area. Thank you. Published March 8, 2024 Created by Related Presenters Anais Hausvater, MD View full profile
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