Cardiovascular Disease
Loren Bonner
A new report from the American Heart Association (AHA) strongly links adverse pregnancy outcomes with a woman’s risk of developing cardiovascular disease (CVD).
The scientific statement, which was published in AHA’s journal Circulation in March 2021, highlights the importance of evaluating CVD risk in women with prior adverse pregnancy outcomes.
According to Nisha Parikh, MD, MPH, one of the statement authors, women with known adverse pregnancy outcomes should be screened more frequently for hypertension, dyslipidemia, and diabetes as well as have their risk aggressively modified as appropriate.
Actionable recommendations
The statement authors noted reliable data to support this connection, with much of the evidence given a strong grading level.
“The fact that several [adverse pregnancy outcomes] were related to CVD in such a robust manner was striking, and yet accounting for these factors in our history-taking and risk factor management is lagging,” said Parikh, who is also an associate professor of medicine in the division of cardiology at the University of California, San Francisco.
“Our statement goes a step further and gives actionable recommendations, emphasizes race [and] ethnic disparities, and discusses pharmacotherapy and health-system roles in promoting care transitions,” Parikh said.
She noted that aspirin, statins, and other cardiometabolic disease prevention medications may have a role in preventing CVD among women with prior adverse pregnancy outcomes. For example, the U.S. Preventive Task Force as well as some medical societies recommend low-dose aspirin to reduce the risk of developing preeclampsia. In published literature, metformin has also been shown to reduce type 2 diabetes not only in the general population, but specifically for women with a history of gestational diabetes.
“We don’t understand all of the pathways linking [adverse pregnancy outcomes] and CVD, those that are independent of established risk factors,” said Parikh. “We also have very little data on non-White women.”
Recommendations for reducing CVD deaths among women
Even though cardiovascular disease (CVD) is the leading cause of death in women, it remains understudied, underdiagnosed, and undertreated in what accounts for half of the world’s population.
In a new first-of-its-kind report published May 16, 2021, in the Lancet, a commission of experts from several different countries laid out 10 recommendations for reducing CVD deaths among women, including increasing women’s participation in clinical trials for heart health treatment and training health care providers more appropriately to screen at-risk women and guide them through disease prevention.
The full report is available at apha.us/CVDLancetReport.
Adverse pregnancy outcomes, defined by AHA
“One of several maternal or fetal complications, including preeclampsia, gestational hypertension, gestational diabetes, preterm delivery, fetal growth restriction, having a neonate with a low birth weight or a low birth weight indexed to a referent sample based on gestational age, and placental abruption.”
Key findings
- A history of adverse pregnancy outcomes in women is a prompt for more vigorous primordial prevention of CVD risk factors and primary prevention of CVD.
- Adopting a heart-healthy diet and increasing physical activity among women with adverse pregnancy outcomes, starting in the postpartum setting and continuing across the life span, are important lifestyle interventions to decrease CVD risk.
- Lactation and breastfeeding may lower a woman’s later cardiometabolic risk.
- Black and Asian women experience a higher proportion of adverse pregnancy outcomes, with more severe clinical presentation and worse outcomes, than White women.
- More studies on adverse pregnancy outcomes and CVD in non-White women are needed to better understand and address these health disparities.
- Future studies of aspirin, statins, and metformin may better inform recommendations for pharmacotherapy in primary CVD prevention among women who have had an adverse pregnancy outcome.
- Several opportunities exist for health care systems to improve transitions of care for women with adverse pregnancy outcomes and to implement strategies to reduce their long-term CVD risk. (One proposed strategy is to incorporate the concept of a fourth trimester into clinical recommendations and health care policy.)
The report is available at apha.us/AHAreportCVD.