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.
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.
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.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
References and Recommended Reading
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
Brennan LJ, Morton JS, Davidge ST. Vascular dysfunction in preeclampsia. Microcirculation. 2014;21:4–14.
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.
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.
Wikstrom AK, Haglund B, Olovsson M, Lindeberg SN. The risk of maternal ischaemic heart disease after gestational hypertensive disease. BJOG. 2005;112:1486–91.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Borlaug BA, Redfield MM. Diastolic and systolic heart failure are distinct phenotypes within the heart failure spectrum. Circulation. 2011;123:2006–13.
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.
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.
Mohseni Z, Spaanderman MEA, Oben J et al. Cardiac remodelling and preeclampsia: an overview of overlapping miRNAs. Ultrasound Obstet Gynecol. 2017.
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.
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.
Ray JG, Schull MJ, Kingdom JC, Vermeulen MJ. Heart failure and dysrhythmias after maternal placental syndromes: HAD MPS Study. Heart. 2012;98:1136–41.
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.
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.
Nerenberg KA, Park AL, Vigod SN, et al. Long-term risk of a seizure disorder after eclampsia. Obstet Gynecol. 2017;130:1327–33.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Conflict of Interest
The authors declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Pregnancy and Cardiovascular Disease
About this article
Cite this article
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
- Hypertensive disorders of pregnancy
- Cardiovascular disease
- Myocardial infarction
- Heart failure