Hypertensive Pregnancy Disorders Linked to Cardiac Abnormalities

Compared with women with normotensive pregnancies, women who develop various hypertensive disorders during pregnancy (HDP) have a greater risk of cardiac structure abnormalities in the decade after childbirth, according to a study in Journal of the American College of Cardiology.

In particular, women with HDP and high blood pressure at the study’s baseline assessment were shown to be most at risk for these changes. They also had subsequent worse left heart diastolic function.

HDPs, which include pre-eclampsia and gestational hypertension (systolic [SBP] and diastolic blood pressure [DBP] > 140 and 90 mm Hg, respectively), result in severely elevated blood pressure and can increase the risk of stroke, heart attack, and eye and kidney damage.

“The changes, which mainly affect the left ventricle of the heart, may predispose some women to ischemic heart disease and heart failure later in life without them knowing it,” the authors said in a statement.

The short-term effects of HDP are well-known and include changes in left ventricular (LV) and right ventricular (RV) function “that can persist up to 1 year postpartum,” the authors noted. However, the longer-term effects are not as well understood, and conclusions from previous studies are mixed.

Among the 132 women in the study (102 with normotensive pregnancies; 30 with HDP history [21, pre-eclampsia; 9, gestational hypertension]), the mean (SD) age was 39 (6) years and body mass index (BMI) was the only significant difference between those who did and did not undergo an echocardiogram: 31.4 (8.3) vs 29.7 (7.8) kg/m2, respectively.

University of Pittsburgh’s Magee Obstetric Maternal and Infant database provided the data on the women (enrolled 2017-2019) with deliveries between 2008 and 2009 who provided placental pathology specimens as part of another study on placental vascular lesions, adverse pregnancy outcomes, and postpartum cardiovascular disease. A randomized subset underwent 2-dimensional transthoracic B-mode, Doppler, and strain echocardiography between 2017 and 2020.

Twenty-nine percent of the women with pre-eclampsia had a severe case of the condition and 33% had a preterm delivery. Overall, 13% of those with pre-eclampsia had the condition during a nonindex pregnancy.

Analyses also found the women with HDP during their index pregnancy, compared with those without HDP, were more at risk for the following 8 to 10 years after delivery:

• Hypertension: 63.3% vs 25.5% (P < .0001)
• Diabetes: 20.7% vs 7.0% (P = .03)
• Higher mean SBP: 125 (12) vs 114 (13) mm Hg (P < .0001)
• Higher mean DBP: 82 (10) vs 74 (9) mm Hg (P < .0001)
• Greater proportion of maternal vascular malperfusion (MVM) lesions during pregnancy: 63.3%vs 45.1% (P = .08)

Following adjustment for age and race, women with HDP also were shown to be at higher risk for LV wall thickness (P = .71), higher biplane LV ejection fraction (LVEF; P = .004), lower mitral inflow E/A ratio (P = .14), and higher relative wall thickness (RWT; (P = .04). Additional adjustments for BMI, current hypertension, and hemoglobin A1C (HbA1C) showed associations between HDP and LV interventricular septum thickness (P = .04), higher RWT (P = .04), and higher biplane LVEF (P = .004).

HDP was also shown to be an independent predictor of LV remodeling (adjusted odd ratio [aOR], 3.2; 95% CI, 1.2-8.5; P = .02) after a logistic regression model that adjusted for age, race, and placental MVM. However, this was lessened after an additional adjustment for BMI, current hypertension, and HbA1C (aOR, 2.5; 95% CI, 0.84-7.7; P = .10).

Overall, HDP history and current hypertension resulted in more instances of LV remodeling compared with all other study groups:

• HDP plus hypertension: 79.0%
• Only HDP: 36.4% (P = .01)
• Only current hypertension: 46.2% (P = .02)
• Neither HDP nor hypertension: 38.2% (P < .001)

“Prior longitudinal cohort studies have suggested that hypertension partially, but incompletely, accounts for HDP’s association with coronary artery disease and heart failure,” the authors noted. “Additionally, we did not see significant structural cardiac changes among women with only hypertension in our study, suggesting that HDP history adds an adverse pathological mechanism beyond the adverse effects of hypertension alone.”

Because LV remodeling and hypertrophy have been linked to greater risks of ischemic heart disease, heart failure, arrhythmia, and mortality, and RWT to LV dysfunction and clinical heart failure, a great need remains to identify women with a history of HDP who may be at risk of any or all of these conditions.

“Those with both HDP history and current hypertension have the most pronounced differences in cardiac structure and function, including the highest proportion of LV remodeling and abnormal diastolic function parameters,” the authors concluded. “This suggests a ‘double-hit’ phenomenon of HDP history and current hypertension warranting closer surveillance and early and targeted therapies for CVD prevention in this higher-risk group.”

Future research should also focus on lifestyle interventions, optimal therapeutic approaches, and treating and preventing known risk factors, with a goal of changing women’s risk trajectory.

Reference

Countouris ME, Villanueva FS, Berlacher KL, Cavalcante JL, Parks, WT, Catove JM. Association of hypertensive disorders of pregnancy with left ventricular remodeling later in life. J Am Coll Cardiol. 2021;77(8):1057-1068. doi:10.1016/j.jacc.2020.12.051