Hypertensive Disorders of Pregnancy and Cardiovascular Diseases: Current Knowledge and Future Directions

Abstract

Purpose of the review

Cardiovascular diseases (CVDs) are the principal killers of women. In this review, we summarize data regarding CVD and mortality after hypertensive disorders of pregnancy (HDP), and highlight clinical, research and policy needs to mitigate this risk.

Recent findings

Robust data indicate that women with HDP have substantially higher risk of future CVD, with a 3.7-fold increase in the risk of chronic hypertension, a 4.2-fold increase in the risk of heart failure, an 81% increase in the risk of stroke, and double the risk of atrial arrhythmias, coronary heart disease, and mortality when compared to women with normotensive pregnancies. Potential explanations include (1) the effect of pregnancy as a “stress test” in women destined to develop CVD, (2) mediation by conventional risk factors, (3) long-term vascular damage sustained during the preeclamptic episode, and (4) preexisting abnormalities in arterial health predisposing women to HDP, and, subsequently, CVD.

Summary

Women with HDP have significantly increased risk of CVD and mortality. Risk scores including obstetric history are necessary to better estimate a woman’s cardiovascular risk. In addition, comprehensive policies promoting systematic risk assessment and modification after HDP are critically needed to improve health, wellness, and survival of affected women.

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References and Recommended Reading

  1. 1.

    Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–e292.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study. Lancet. 2005;366:1797–803.

    Article  PubMed  Google Scholar 

  3. 3.

    Mongraw-Chaffin ML, Cirillo PM, Cohn BA. Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort. Hypertension. 2010;56:166–71.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  4. 4.

    Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P, Committee SHG. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can. 2014;36:575–6.

    Article  PubMed  Google Scholar 

  5. 5.

    Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2007;335:974.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Wu P, Haththotuwa R, Kwok CS et al. Preeclampsia and future cardiovascular health: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2017;10.

  7. 7.

    Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937–52.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P, Canadian Hypertensive Disorders of Pregnancy Working G. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can. 2014;36:416–41.

    Article  PubMed  Google Scholar 

  9. 9.

    Smith GN, Pudwell J, Walker M, Wen SW. Risk estimation of metabolic syndrome at one and three years after a pregnancy complicated by preeclampsia. J Obstet Gynaecol Can. 2012;34:836–41.

    Article  PubMed  Google Scholar 

  10. 10.

    Hermes W, Franx A, van Pampus MG, et al. Cardiovascular risk factors in women who had hypertensive disorders late in pregnancy: a cohort study. Am J Obstet Gynecol. 2013;208:474 e1–8.

    Article  Google Scholar 

  11. 11.

    Khalil A, Garcia-Mandujano R, Maiz N, Elkhouli M, Nicolaides KH. Longitudinal changes in maternal hemodynamics in a population at risk for pre-eclampsia. Ultrasound Obstet Gynecol. 2014;44:197–204.

    Article  PubMed  CAS  Google Scholar 

  12. 12.

    Khalil AA, Cooper DJ, Harrington KF. Pulse wave analysis: a preliminary study of a novel technique for the prediction of pre-eclampsia. BJOG. 2009;116:268–76. discussion 276-7

  13. 13.

    Brennan LJ, Morton JS, Davidge ST. Vascular dysfunction in preeclampsia. Microcirculation. 2014;21:4–14.

    Article  PubMed  Google Scholar 

  14. 14.

    Yinon Y, Kingdom JCP, Odutayo A, et al. Vascular dysfunction in women with a history of preeclampsia and intrauterine growth restriction / clinical perspective. Circulation. 2010;122:1846–53.

    Article  PubMed  CAS  Google Scholar 

  15. 15.

    Orabona R, Sciatti E, Vizzardi E, et al. Endothelial dysfunction and vascular stiffness in women with previous pregnancy complicated by early or late pre-eclampsia. Ultrasound Obstet Gynecol. 2017;49:116–23.

    Article  PubMed  CAS  Google Scholar 

  16. 16.

    Wikstrom AK, Haglund B, Olovsson M, Lindeberg SN. The risk of maternal ischaemic heart disease after gestational hypertensive disease. BJOG. 2005;112:1486–91.

    Article  PubMed  Google Scholar 

  17. 17.

    Sibai BM, el-Nazer A, Gonzalez-Ruiz A. Severe preeclampsia-eclampsia in young primigravid women: subsequent pregnancy outcome and remote prognosis. Am J Obstet Gynecol. 1986;155:1011–6.

    Article  PubMed  CAS  Google Scholar 

  18. 18.

    Behrens I, Basit S, Melbye M, et al. Risk of post-pregnancy hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study. BMJ. 2017;358:j3078.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Timpka S, Stuart JJ, Tanz LJ, Rimm EB, Franks PW, Rich-Edwards JW. Lifestyle in progression from hypertensive disorders of pregnancy to chronic hypertension in Nurses’ health study II: observational cohort study. BMJ. 2017;358:j3024.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Callaway LK, David McIntyre H, Williams GM, Najman JM, Lawlor DA, Mamun A. Diagnosis and treatment of hypertension 21 years after a hypertensive disorder of pregnancy. Aust N Z J Obstet Gynaecol. 2011;51:437–40.

    Article  PubMed  Google Scholar 

  21. 21.

    MacDonald SE, Walker MC, Ramshaw H, Godwin M, Chen X-k, Smith GN. Hypertensive disorders of pregnancy and long-term risk of hypertension: what do Ontario prenatal care providers know, and what do they communicate? J Obstet Gynaecol Can. 2007;29:705–10.

    Article  PubMed  Google Scholar 

  22. 22.

    Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension. 2008;52:818–27.

    Article  PubMed  CAS  Google Scholar 

  23. 23.

    Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–322.

    Article  PubMed  Google Scholar 

  24. 24.

    Cheng S, Claggett B, Correia AW, et al. Temporal trends in the population attributable risk for cardiovascular disease: the Atherosclerosis Risk in Communities Study. Circulation. 2014;130:820–8.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Riise HK, Sulo G, Tell GS et al. Incident coronary heart disease after preeclampsia: role of reduced fetal growth, preterm delivery, and parity. J Am Heart Assoc. 2017;6.

  26. 26.

    Auger N, Fraser WD, Schnitzer M, Leduc L, Healy-Profitos J, Paradis G. Recurrent pre-eclampsia and subsequent cardiovascular risk. Heart. 2017;103:235–43.

    Article  PubMed  Google Scholar 

  27. 27.

    Yusuf S, Hawken S, Ounpuu S, et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet. 2005;366:1640–9.

    Article  PubMed  Google Scholar 

  28. 28.

    Behrens I, Basit S, Lykke JA, et al. Association between hypertensive disorders of pregnancy and later risk of cardiomyopathy. J Am Med Assoc. 2016;315:1026–33.

    Article  CAS  Google Scholar 

  29. 29.

    Bello N, Rendon ISH, Arany Z. The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis. J Am Coll Cardiol. 2013;62:1715–23.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Borlaug BA, Redfield MM. Diastolic and systolic heart failure are distinct phenotypes within the heart failure spectrum. Circulation. 2011;123:2006–13.

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Ho JE, Gona P, Pencina MJ, et al. Discriminating clinical features of heart failure with preserved vs. reduced ejection fraction in the community. Eur Heart J. 2012;33:1734–41.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Alma LJ, Bokslag A, Maas A, Franx A, Paulus WJ, de Groot CJM. Shared biomarkers between female diastolic heart failure and pre-eclampsia: a systematic review and meta-analysis. ESC Heart Fail. 2017;4:88–98.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Mohseni Z, Spaanderman MEA, Oben J et al. Cardiac remodelling and preeclampsia: an overview of overlapping miRNAs. Ultrasound Obstet Gynecol. 2017.

  34. 34.

    Orabona R, Sciatti E, Vizzardi E, et al. Elastic properties of ascending aorta in women with previous pregnancy complicated by early- or late-onset pre-eclampsia. Ultrasound Obstet Gynecol. 2016;47:316–23.

    Article  PubMed  CAS  Google Scholar 

  35. 35.

    Orabona R, Vizzardi E, Sciatti E, et al. Insights into cardiac alterations after pre-eclampsia: an echocardiographic study. Ultrasound Obstet Gynecol. 2017;49:124–33.

    Article  PubMed  CAS  Google Scholar 

  36. 36.

    Ray JG, Schull MJ, Kingdom JC, Vermeulen MJ. Heart failure and dysrhythmias after maternal placental syndromes: HAD MPS Study. Heart. 2012;98:1136–41.

    Article  PubMed  Google Scholar 

  37. 37.

    Benjamin EJ, Levy D, Vaziri SM, D'Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. J Am Med Assoc. 1994;271:840–4.

    Article  CAS  Google Scholar 

  38. 38.

    Fields JA, Garovic VD, Mielke MM, et al. Preeclampsia and cognitive impairment later in life. Am J Obstet Gynecol. 2017;217:74.e1–74.e11.

    Article  Google Scholar 

  39. 39.

    Nerenberg KA, Park AL, Vigod SN, et al. Long-term risk of a seizure disorder after eclampsia. Obstet Gynecol. 2017;130:1327–33.

    Article  PubMed  Google Scholar 

  40. 40.

    Aukes AM, de Groot JC, Wiegman MJ, Aarnoudse JG, Sanwikarja G, Zeeman GG. Long-term cerebral imaging after pre-eclampsia. BJOG. 2012;119:1117–22.

    Article  PubMed  CAS  Google Scholar 

  41. 41.

    Andolf EG, Sydsjo GC, Bladh MK, Berg G, Sharma S. Hypertensive disorders in pregnancy and later dementia: a Swedish National Register Study. Acta Obstet Gynecol Scand. 2017;96:464–71.

    Article  PubMed  Google Scholar 

  42. 42.

    Weissgerber TL, Turner ST, Bailey KR, et al. Hypertension in pregnancy is a risk factor for peripheral arterial disease decades after pregnancy. Atherosclerosis. 2013;229:212–6.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  43. 43.

    Emdin CA, Anderson SG, Callender T, et al. Usual blood pressure, peripheral arterial disease, and vascular risk: cohort study of 4.2 million adults. BMJ. 2015;351:h4865.

    Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. New Engl J Med. 1992;326:381–6.

    Article  PubMed  CAS  Google Scholar 

  45. 45.

    Butalia S, Audibert F, Cote AM, et al. Hypertension Canada’s 2018 guidelines for the management of hypertension in pregnancy. Can J Cardiol. 2018; https://doi.org/10.1016/j.cjca.2018.02.021.

  46. 46.

    Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243–62.

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Anderson TJ, Gregoire J, Pearson GJ, et al. 2016 Canadian cardiovascular society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol. 2016;32:1263–82.

    Article  PubMed  Google Scholar 

  48. 48.

    Smith GN, Pudwell J, Walker MC, Wen S-W, for the Pre-Eclampsia New Emerging Team (PE- NET). Ten-year, thirty-year, and lifetime cardiovascular disease risk estimates following a pregnancy complicated by preeclampsia. J Obstet Gynaecol Can. 2012;34:830–5.

    Article  PubMed  Google Scholar 

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Acknowledgements

Dr. Thais Coutinho is a Clinician Scientist supported by a Heart and Stroke Foundation of Ontario Clinician Scientist Phase I Award and holds the Chair of Women’s Heart Health at the University of Ottawa Heart Institute. Dr. Kara Nerenberg is a Clinician Scientist supported by a Heart and Stroke Foundation of Alberta New Investigator Award.

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Correspondence to Thais Coutinho MD.

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This article is part of the Topical Collection on Pregnancy and Cardiovascular Disease

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Coutinho, T., Lamai, O. & Nerenberg, K. Hypertensive Disorders of Pregnancy and Cardiovascular Diseases: Current Knowledge and Future Directions. Curr Treat Options Cardio Med 20, 56 (2018). https://doi.org/10.1007/s11936-018-0653-8

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Keywords

  • Preeclampsia
  • Hypertensive disorders of pregnancy
  • Cardiovascular disease
  • Myocardial infarction
  • Stroke
  • Heart failure