Cardiovascular disease continues to be the leading cause of death in women worldwide [1,2,3]. In the past several decades, intensive research efforts have focused on modifying the risk of CVD and promoting primary prevention strategies. Sex-specific risk factors, particularly those related to pregnancy, are known to have accompanying risks for CVD [15, 16]. Vascular damage and placental dysfunction occurring during gestation may share some of the underlying mechanisms for future CVD or may be the trigger for alternative pathways of injury [6]. There is a sufficient body of evidence in recent literature to suggest that women with a history of APOs are more likely to develop CVD later in life than those without [4, 7,8,9,10, 12]. This offers a unique window of opportunity to properly screen for, identify and provide early intervention strategies in women with a history of APOs. However, whether sufficient knowledge exists within various specialties to facilitate screening is unknown. Through this study, we determined that physicians in the investigated specialties from an academic institution were not aware of the association between APOs and CVD, the various types of APOs or their associated secondary risk factors. In addition, there was a knowledge deficiency in screening frequencies and of guidelines for follow-up management for a given APO. Interestingly, in this study, physicians’ knowledge regarding the associations between APO and CVD did not affect screening rates for CVD. A review of the most current AHA and ACOG guidelines recommends that all pregnancies involving PE, GDM and PTB need to be recognized as an APO, with the women at increased risk of developing type 2 diabetes mellitus, ischemic heart disease, chronic hypertension, stroke and heart failure [12,13,14,15,16]. These guidelines also suggest the need of an annual follow-up for blood pressure, lipids, fasting glucose and body mass index screening [12, 13, 16]. It is important to note, however, that the starting time and the frequency of follow-up differ amongst the international societies and associations [13].
APOs are likely familiar to and easily recognized by those physicians managing these complications, whereas to others not cognizant of these APOs, preventative measures for future CVD may be missed. Preterm birth is defined as a delivery at < 37 weeks gestation, and sometimes the patient may not be aware of the precise gestational age at delivery. The distinction is important as those women with either spontaneous preterm birth at < 32 weeks gestation, those delivered preterm for medical conditions or those with pre-eclampsia are at particularly higher risk for future composite CVD death (adjusted odds ratio 1.8) [11]. Other researchers have reported similar risks for future CVD as well as nearly a fourfold increased relative risk for hypertensive disease in those with a prior pregnancy complicated by pre-eclampsia [12].
Thus, the results of our survey suggest that an opportunity exists to raise physician awareness of APOs and to provide continuous medical education about APOs and their association with future CVD risk. Such knowledge has the potential to translate into educational initiatives targeted toward multi-disciplinary education on this topic as well as clear guidelines for screening women. Increasing awareness of these associations is a step towards improving identification of APOs as CVD risk factors, promoting risk reduction strategies and improving risk factor screening. This is particularly important in young women who have varied sources of primary care, such as those specialties assessed in our study. Given that pregnancy often occurs in a woman’s life before the onset of CVD symptoms, establishing proper screening for APOs affords opportunities for risk mitigation through lifestyle modification and pharmacotherapy for hypertension as well as lipid-lowering therapies where indicated. Although conventional CVD risk calculators do not include consideration of APOs, the most recent primary prevention and lipid guidelines now include consideration of APOs as risk-enhancers for lipid therapy [6]. Thus, APOs continue to emerge as an important part of risk assessment, particularly in young, often otherwise healthy women, and knowledge of such a medical history can guide not only risk assessment but also risk modification.
Limitations
The current study has a numbe of limitations. First, in this preliminary study, the sample size is small, thus the results are exploratory. Second, the responses to our questionnaire were voluntary, thus introducing potential bias. Mean age of the patients seen by different providers was not queried which may influence provider risk assessment. Additionally, this was a single-center study and results may not be applicable to other institutions.