According to recent estimates, about 85% of women in the United States experience pregnancy and childbirth, but as many as 30% of pregnancies are complicated by one or more adverse pregnancy outcomes (APOs). Several APOs have been linked to higher risks for developing cardiovascular disease (CVD), including gestational diabetes, hypertensive disorders of pregnancy (HDP), preterm delivery, and infants with low or high birth weight.
Previous research has suggested that preeclampsia, gestational hypertension, and gestational diabetes may be associated with an increased risk for developing heart failure (HF). However, these studies often do not consider the associations of multiple APOs with HF. Studies distinguishing between HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) are also lacking because of limited HF phenotyping.
Study Examines Long-Term Associations
For a study published in JAMA Network Open, Nisha I. Parikh, MD, MPH, and colleagues investigated the association of APOs with incident HF overall among postmenopausal women in the Women’s Health Initiative. The authors also stratified patients by HF subtype (HFpEF vs HFrEF). “The Women’s Health Initiative provided a unique opportunity to study these associations in a large, diverse group of women who had carefully measured HF outcomes,” says Dr. Parikh.
An APO history survey was administered to postmenopausal women aged 50-79 to analyze associations of five APO —gestational diabetes, HDP, low birth weight, high birth weight, and preterm delivery—with incident adjudicated HF. Logistic regression models were used to assess the association of each APO with HF. Multinomial regression was used to evaluate associations of each APO with HF subtypes, adjusting for age, sociodemographic characteristics, smoking, randomization status, reproductive history, and other APOs.
History of HDP Associated With HF Later in Life
Of the more than 10,000 women included in the study, 31% reported having one or more APOs, and slightly more than 3% had an HF diagnosis. Women with a history of any APO had a higher prevalence of hypertension, diabetes, coronary heart disease, or smoking. Of all the APOs studied, a history of HDP was independently associated with a 1.75-fold higher risk for developing subsequent HF (Figure). This association was significant even after adjusting for multiple confounding factors, including other APOs.
The study also showed that HDP was significantly associated with developing HFpEF—but not HFrEF—in postmenopausal women, independent of conventional HF risk factors, other APOs, and sociodemographic and reproductive factors. “In our large cohort of older women, a history of HDP—including gestational hypertension and preeclampsia—was associated with later HF, particularly HFpEF,” Dr. Parikh says. “Hypertension, coronary heart disease, and obesity were risk factors that may have led to HF in women with HDP.”
In Women With HDP, Monitor & Modify Risk Factors
Based on the findings, the study group recommended that women presenting with a history of HDP be closely monitored. This may provide opportunities for early and aggressive preventive interventions for HF and other CVDs. Ideally, these patients will be identified before they develop traditional risk cardiovascular risk factors, such as hypertension, diabetes, and obesity
“Taking a pregnancy history in patients is also important, even if women are well past their childbearing years,” adds Dr. Parikh. “Our findings suggest that monitoring and modifying blood pressure and weight and making efforts to prevent coronary heart disease early in women with HDP may be associated with reduced long-term risks for HF.”
Long-term studies are needed to assess the extent to which earlier cardiovascular prevention strategies will be effective in women with a history of HDP. “In future research, it will be important to look at specific mechanisms connecting HDP with later development of HF,” Dr. Parikh says. Dedicated studies are also needed to establish effective interventions to mitigate long-term risks for HF and other CVDs in women with APOs. “It’s critical that we discover which therapies will prevent HF after HDP is identified in patients,” says Dr. Parikh.
