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Hypertensive Pregnancy Disorders Tied to Double Hypertension Risk

Hypertensive disorders of pregnancy (HDP) are associated with a greater than twofold risk of developing hypertension a decade later, new research suggests.

Investigators prospectively studied patients who had and who had not experienced HDP 10 years earlier; most self-identified as Black. They found that those with a history of HDP had a 2.4-fold higher risk for new hypertension than those without such a history.

Patients who developed hypertension showed greater left ventricular (LV) remodeling (including greater relative wall thickness), worse diastolic function, more abnormal longitudinal strain, and higher effective arterial elastance than those without hypertension, regardless of the presence or absence of an HDP history.

“We know that patients with pre-eclampsia are at a higher risk for heart disease later in life, and it seems to be driven by the development of new hypertension,” lead author Lisa Levine, MD, MSCE, director, pregnancy and heart disease program, Hospital of the University of Pennsylvania, Philadelphia, told theheart.org | Medscape Cardiology.

It is critically important to “study a more diverse population, including a larger percentage of Black patients, since HDP and CVD both disproportionately affect Black women,” Levine said. “And it is important to screen patients for hypertension, getting them into primary care for visits, getting them diagnosed sooner, and treating them early for hypertension.”

The study was published in the June 21 issue of the Journal of the American College of Cardiology.

Understudied Population

HDP includes gestational hypertension and pre-eclampsia, Levine explained. “We already know that patients who have had pre-eclampsia are at higher risk for stroke, heart failure (HF), and myocardial infarction (MI) later in life,” she said. The goal of this study was to see whether, instead of waiting 20 to 30 years, they could look only 10 years later to see which patients would be at highest risk for future heart disease, Levine said.

In particular, it’s known that CVD and HDP “disproportionately affect Black women,” Levine continued. “What makes our study different from other studies is that we focused predominantly on the Black African American population, since it’s understudied and also at highest risk for pre-eclampsia and heart disease,” she said.

They set out to “evaluate differences in CV risk factors as well as subclinical CVD among a well-characterized group of racially diverse patients with and without a history of HDP 10 years earlier,” the authors state.

To investigate the question, the researchers performed a prospective, cross-sectional study between April 2016 and December 2019 of patients with and without a diagnosis of HDP during a previous pregnancy at least 10 years earlier (from 2005 to 2007). Patients were drawn from a parent cohort in a previously performed observational study of patients with pre-eclampsia or HDP and normotensive control subjects.

The current study focused on 135 patients (85% Black), 84 with a history of HDP and 51 without. Of the Black patients, 91.7% had a history of HDP, compared with 8.3% of the White patients.

During an in-person visit, the researchers assessed participants’ blood pressure and other clinical risk factors for CVD, including fasting glucose and lipids. They also used noninvasive means to measure cardiac and vascular structure and function.

Measurement of Cardiac and Vascular Structure and Function
Vascular Structure and Function Noninvasive Measure
Cardiac structure/function (including LV ejection fraction and wall thickness) Echocardiography
Large artery and muscular artery stiffness Carotid-femoral and carotid-radial pulse wave velocity
Hemodynamic arterial function Arterial tonometry and Doppler echocardiography
Endothelial function Flow-mediated dilation of the brachial artery

Importance of Routine Screening

The risk for new hypertension was 2.4 times higher in patients with a history of HDP than in those without HDP, with stage 2 hypertension noted in 56.0% of patients with and in 23.5% without HDP (P < .001). This equates to a relative risk of 2.4 (95% CI, 1.39 – 4.14), even after adjustment for race, maternal age, BMI, and history of preterm birth.

“Importantly, 18% of patients with a history of HDP met criteria for a new diagnosis of hypertension identified through the study visit,” the authors report.

There were no differences in many cardiac measures (LV structure, global longitudinal strain, diastolic function, arterial stiffness, or endothelial function) between patients with and without a history of HDP.

However, patients with chronic hypertension (CHTN), regardless of HDP history, had other cardiac abnormalities, including greater LV remodeling, worse diastolic function, and higher effective arterial elastance.

“The data regarding increased risk of hypertension after HDP is not a novel finding, however our cohort is unique in the high baseline rate of stage 2 hypertension, even among patients without a history of HDP,” the authors comment.

In fact, when they looked at the diagnosis of either stage 1 or stage 2 hypertension, they found that more than 80% of patients with and 60% of patients without a history of HDP had hypertension. Notably, among patients with a history of HDP, only 39% had a formal diagnosis of either stage 1 or stage 2 hypertension, further highlighting “the importance of routine screening for CHTN in this population,” they state.

“Further studies should evaluate the optimal time period to screen for postpartum hypertension and a monitoring plan for these at-risk women,” Levine added.

“Opportunity of a Lifetime”

Commenting for theheart.org | Medscape Cardiology, Malamo Countouris, MD, MS, assistant professor of medicine and codirector, postpartum hypertension program, University of Pittsburgh Medical Center, said hypertension is “under-recognized and undertreated among young, premenopausal, Black women.”

Pregnancy “gives us a clue, through HDP, as to who is high risk to develop chronic hypertension and subsequent subclinical structural cardiac changes in the decade after delivery,” said Countouris, who was not involved with the study.

“The jury is still out on whether HDP contributes independently to cardiovascular changes in the years after delivery. Ongoing research is needed to clarify the unique or compounding contributions of pregnancy complications and hypertension,” she added.

In an accompanying editorial, Josephine Chou, MD, MS, director of cardio-obstetrics and codirector of maternal cardiology, Yale University School of Medicine, New Haven, Connecticut, called the study a “laudable contribution to understanding of HDP and hypertension within the first decade after pregnancy,” saying that it “paves the way for future efforts to improve postpartum CV care, enabling us to grasp this opportunity of a lifetime to ultimately reduce maternal and pregnancy-related morbidity and mortality.”

This study was supported by the NIH, the National Heart, Lung, and Blood Institute, and the American Association of Obstetricians and Gynecologists Foundation. Levine reports no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Countouris reports receiving funding from the American Heart Association. Chou reports no relevant financial relationships.

J Am Coll Cardiol. 2022;79:2401-2411, 2412-2414. Abstract, Editorial

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