Long-Term Blood Pressure Control After Hypertensive Pregnancy Following Physician-Optimized Self-Management

Abstract

ImportancePregnancy hypertension results in adverse cardiac remodeling and higher incidence of hypertension and cardiovascular diseases in later life.ObjectiveTo evaluate whether an intervention designed to achieve better blood pressure control in the postnatal period is associated with lower blood pressure than usual outpatient care during the first 9 months postpartum.Design, Setting, and ParticipantsRandomized, open-label, blinded, end point trial set in a single hospital in the UK. Eligible participants were aged 18 years or older, following pregnancy complicated by preeclampsia or gestational hypertension, requiring antihypertensive medication postnatally when discharged. The first enrollment occurred on February 21, 2020, and the last follow-up, November 2, 2021. The follow-up period was approximately 9 months.InterventionsParticipants were randomly assigned 1:1 to self-monitoring along with physician-optimized antihypertensive titration or usual postnatal care.Main Outcomes and MeasuresThe primary outcome was 24-hour mean diastolic blood pressure at 9 months postpartum, adjusted for baseline postnatal blood pressure.ResultsTwo hundred twenty participants were randomly assigned to either the intervention group (n = 112) or the control group (n = 108). The mean (SD) age of participants was 32.6 (5.0) years, 40% had gestational hypertension, and 60% had preeclampsia. Two hundred participants (91%) were included in the primary analysis. The 24-hour mean (SD) diastolic blood pressure, measured at 249 (16) days postpartum, was 5.8 mm Hg lower in the intervention group (71.2 [5.6] mm Hg) than in the control group (76.6 [5.7] mm Hg). The between-group difference was −5.80 mm Hg (95% CI, −7.40 to −4.20; P < .001). Similarly, the 24-hour mean (SD) systolic blood pressure was 6.5 mm Hg lower in the intervention group (114.0 [7.7] mm Hg) than in the control group (120.3 [9.1] mm Hg). The between-group difference was −6.51 mm Hg (95% CI, −8.80 to −4.22; P < .001).Conclusions and RelevanceIn this single-center trial, self-monitoring and physician-guided titration of antihypertensive medications was associated with lower blood pressure during the first 9 months postpartum than usual postnatal outpatient care in the UK.Trial RegistrationClinicalTrials.gov Identifier: NCT04273854

Blood Pressure Trajectories Through the First Year Postpartum in Overweight or Obese Individuals Following a Hypertensive Disorder of Pregnancy

“…A similar proportion of individuals were on antihypertensive medications at 6 months postpartum across both arms, but tighter BP control during the critical immediate postpartum period led to lower BP for a long term (−4.5-mm Hg office diastolic BP at 6 months and −6.8-mm Hg ambulatory diastolic BP at 3-4 years). 16,17 These findings were confirmed in the recently published POP-HT trial (Physician Optimised Post-partum Hypertension Treatment Trial), which demonstrated sustained benefits to ambulatory diastolic BP at 6 to 9 months postpartum and more favorable cardiac remodeling with short-term optimization of BP through self-monitoring and physician-guided antihypertensive medication titration in the immediate postpartum 18,19 Another small study randomized individuals with preterm preeclampsia to postpartum enalapril and demonstrated improved left ventricular remodeling at 6 months postpartum compared with individuals randomized to placebo. 15 These studies suggest that the immediate postpartum period may be particularly important for cardiovascular remodeling and interventions in this period may improve both short-and long-term cardiovascular risks.…”

Cardiac Remodeling After Hypertensive Pregnancy Following Physician-Optimized Blood Pressure Self-Management: The POP-HT Randomized Clinical Trial Imaging Substudy

“…This was also demonstrated by the significantly lower rates of hospital readmissions for hypertension seen in the intervention arm. 16 It is striking that these reductions in postpartum blood pressure with self-monitoring persist for at least 9 months, even after the women have stopped taking medication, and in SNAP-HT were still evident 4 years later. 33 This persistent effect on blood pressure is consistent with our hypothesis that early postpartum interventions may lead to underlying structural cardiovascular changes, which has now been supported by the current imaging study.…”

“…The primary article reporting blood pressure outcomes has been published and includes a detailed description of recruitment, patient characteristics, and statistical analysis. 16 A protocol article reporting the detailed methodology and prespecified outcome measures, including the secondary imaging outcomes, has previously been published. 17 In brief, all participants were recruited from the Women's Centre at Oxford University Hospitals National Health Service Foundation Trust in the United Kingdom.…”

“…13 Titration of antihypertensive treatment was conducted at the discretion of their supervising health care professionals (primary care physician and midwife). As previously reported, 16 participants in the intervention group had initial discharge medications decided by their clinical care team, 13 and then dose titration after hospital discharge was guided remotely by the research team physicians, including cardiologists and obstetricians, in response to daily self-monitored blood pressure measurements (increased to twice daily if out of target range; see published protocol article for further details). 17 Choice of medication and titration regimens were standardized on the basis of recommendations from the 2019 UK National Institute of Clinical Excellence guidance.…”

“…[12][13][14][15] In the POP-HT (Physician-Optimized Postpartum Hypertension Treatment) randomized clinical trial, we demonstrated physician-guided antihypertensive self-management after hypertensive pregnancy results in lower blood pressure for at least 9 months postpartum. 16 Participants were also invited for multimodality imaging to investigate prespecified secondary imaging outcomes. These were included to test the underlying mechanistic hypothesis that better postpartum blood pressure control induces differences in cardiac structure and function, in parameters of potential relevance to long-term blood pressure control and future cardiovascular disorders, including heart failure.…”