Risk of future cardiovascular diseases in different years postpartum after hypertensive disorders of pregnancy: A systematic review and meta-analysis

Abstract

Objective: There are limited data on the optimal timing and frequency of postpartum follow-up visits after hypertensive disorders of pregnancy (HDP) for primary prevention and early detection of cardiovascular diseases (CVDs) in high-risk women. We aimed to evaluate the risk of cardiovascular outcomes later in life in women with prior HDP in different years postpartum and in preeclamptic women with severe features, or early onset of preeclampsia.Methods: We searched MEDLINE, Cochrane Library, Web of Science, and Scopus without language restriction for relevant articles published from inception to March 16, 2022. We included prospective and retrospective cohort studies assessing hypertension, ischemic heart disease, heart failure, venous thromboembolism, peripheral vascular disease, stroke, dementia, composite cardiovascular and/or cerebrovascular diseases, and mortality after 6 weeks postpartum, in women with prior HDP compared with controls. Two authors independently selected and appraised the studies. Article quality was independently assessed using the Newcastle-Ottawa Scale (NOS). Random-effect models were used for meta-analysis. Stratified analyses based on years postpartum, severity, and onset of preeclampsia were performed.Results: We included 59 studies for qualitative review, of which 56 were included in quantitative meta-analysis, involving 1,262,726 women with prior HDP and 14,711,054 controls. Women with prior HDP had increased risks of hypertension (relative risk [RR] 3.46, 95% confidence interval [CI]: 2.67-4.49), ischemic heart disease (RR 2.06, 95% CI: 1.38-3.08), and heart failure (RR 2.53, 95% CI: 1.28-5.00) later in life, compared with those with normotensive pregnancies. The risk of hypertension was highest during 5 years postpartum (RR 5.34,. Compared with normotensive pregnancies, the risk of future CVDs significantly increased in preeclamptic women.Discussion: A history of HDP is associated with approximately 2-to 4-fold increase in the risk of CVDs. Screening for CVDs and their risk factors in women with prior HDP since delivery, especially the first 5 years after delivery is suggested for early detection and appropriate management. Evidence on the risks of CVDs in preeclampsia with severe features and early onset of preeclampsia is limited due to having few studies and high heterogeneity.

Comparison of Stroke Recurrence, Cardiovascular Events, and Death Among Patients With Pregnancy-Associated vs Non–Pregnancy-Associated Stroke

“…In contrast, we observed a higher risk of acute coronary syndrome with ST-segment elevation in women who had pregnancy-associated stroke. Because pregnancy-associated strokes are partly linked to gestational hypertensive disorders, our finding could be consistent with previous studies that pointed out an excess of cardiovascular morbidity, especially ischemic heart disease, during follow-up of women with HDP . Nevertheless, we observed a lower risk of stroke recurrence in both women with pregnancy-associated stroke with HDP and those without compared with women with non–pregnancy-associated stroke.…”

“…Because pregnancy-associated strokes are partly linked to gestational hypertensive disorders, our finding could be consistent with previous studies that pointed out an excess of cardiovascular morbidity, especially ischemic heart disease, during follow-up of women with HDP. 11 , 12 , 13 , 14 , 15 , 16 Nevertheless, we observed a lower risk of stroke recurrence in both women with pregnancy-associated stroke with HDP and those without compared with women with non–pregnancy-associated stroke. The inverse association between pregnancy and stroke recurrence as well as pregnancy and coronary risk remains unclear and needs further research.…”

Translation of mechanistic advances in preeclampsia to the clinic: Long and winding road

“…197 There is also a strong association between a history of preeclampsia and an increased risk of future cardiovascular disease. 191,192,194,[204][205][206][207][208][209][210][211] Early onset preeclampsia, which occurs before 34 weeks of gestation, is particularly concerning as it is linked with a higher burden of future cardiovascular morbidity (hypertension, stroke, arrythmias, ischemic heart disease) and mortality compared to late-onset preeclampsia. 191,210,212 A large cohort study involving 14 403 patients found that the hazard ratio for cardiovascular disease (CVD) death was 9.54 (95% CI: 4.50-20.26) in women with early onset preeclampsia and 1.26 (95% CI: 1.26-3.44) for those with late-onset disease.…”

“…There is also a strong association between a history of preeclampsia and an increased risk of future cardiovascular disease 191,192,194,204–211 . Early onset preeclampsia, which occurs before 34 weeks of gestation, is particularly concerning as it is linked with a higher burden of future cardiovascular morbidity (hypertension, stroke, arrythmias, ischemic heart disease) and mortality compared to late‐onset preeclampsia 191,210,212 .…”

Where Do We Go From Here: Reflections on a Century in Women’s Cardiovascular Health Research, 1924–2024

“…One example is the relatively recently developed evidence base regarding the associations between hypertensive disorders of pregnancy and early and heightened risk of CVD. [8][9][10] A search of the historical PubMed database reveals that leading up to the year 2024, studies examining hypertensive disorders of pregnancy comprise <5% of all indexed articles published over the last century on the associations between hypertension and CVD.…”