Randomized Trial to Reduce Cardiovascular Risk in Women with Recent Preeclampsia

Optimizing women's cardiovascular health after hypertensive disorders of pregnancy: a translational approach to cardiovascular disease prevention

Women who experience a hypertensive disorder of pregnancy (HDP) are amongst those at the highest risk of premature cardiovascular diseases (CVD). In Canada, effective CVD prevention interventions tailored specifically for this high-risk population are urgently needed. The objective of this review is to summarize a broad range of mechanistic and clinical studies examining the association of HDP with future CVD to inform postpartum clinical follow-up strategies focused on improving women's cardiovascular health. The current state of the science (animal model, observational and intervention studies) largely support two main hypotheses explaining the epidemiological link between HDP and long-term risk of CVD. First, that the complicated pregnancy "unmasks" women who were predisposed to CVD prior to pregnancy (i.e., women with subclinical atherosclerosis or pre-pregnancy CVD risk factors). Second, that HDP causes vascular dysfunction and/or worsens preexisting, subclinical CVD risk factors. Despite this strong evidence, several knowledge gaps remain in the understanding of specific mechanisms linking these two theories and the impacts of other important contributors (e.g., intersectional factors). From a clinical perspective, given the consistent data demonstrating a high prevalence of CVD risk factors after HDP, routine care after pregnancy at minimum should include: 1) standardized assessment of pregnancy-associated CV risks (P-CVRs); 2) early and regular screening of traditional CVD risk factors; 3) education and support for health behaviours as first line therapy (including breastfeeding); 4) individualized pharmacotherapy (i.e., statins, antihypertensives or antiglycemic agents as clinically indicated); and 5) consideration of a woman's health goals, reproductive plans and social context.

Evidence-Based Recommendations for Medical Management of Peripheral Artery Disease

Patients with lower limb artery stenosis or occlusion (peripheral artery disease; PAD) have been determined to be at very high risk of both major adverse cardiovascular events, such as myocardial infarction and stroke, and major adverse limb events, such as amputation and requirement for artery surgery.Effective medical management has been identified as key in reducing this risk; however, this is often poorly implemented in clinical practice. Thus, the aim of this narrative review was to summarize the current evidence on the medical management of PAD in order to inform clinicians and highlight recommendations for clinical practice. International guidelines, randomized controlled trials, and relevant systematic reviews and meta-analyses have been included in this study. The focus was the management of the key modifiable risk factors to mitigate possible adverse events through prescription of anti-platelet and anticoagulation drugs and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes and aid smoking cessation. The available evidence from randomized clinical trials provide a strong rationale for the need for holistic medical management programs that are effective in achieving uptake of these medical therapies in patients with PAD. In conclusion, people with PAD have some of the highest adverse event rates among those with cardiovascular diseases. Secondary preventive measures have been proven effective in reducing these adverse events; however, they remain to be adequately implemented. Thus, the need for an effective implementation program has emerged to reduce adverse events in this patient group.

Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association

This statement summarizes evidence that adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss increase a woman's risk of developing cardiovascular disease (CVD) risk factors and of developing subsequent CVD (including fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, and heart failure). This statement highlights the importance of recognizing APOs when CVD risk is evaluated in women, although their value in reclassifying risk may not be established. A history of APOs 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 APOs, 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 APOs, with more severe clinical presentation and worse outcomes, than White women. More studies on APOs 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 our recommendations for pharmacotherapy in primary CVD prevention among women who have had an APO. Several opportunities exist for health care systems to improve transitions of care for women with APOs and to implement strategies to reduce their long-term CVD risk. One proposed strategy includes incorporation of the concept of a fourth trimester into clinical recommendations and health care policy.

Association of Hypertensive Disorders of Pregnancy With Left Ventricular Remodeling Later in Life

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are associated with short-term cardiac structure and function abnormalities, but later life changes are not well studied.

OBJECTIVES

This study aimed to determine if HDP history is associated with echocardiographic differences 8 to 10 years after delivery, and if subgroups with placental maternal vascular malperfusion (MVM) lesions or current hypertension may be particularly affected.

METHODS

Women with pregnancies delivered from 2008 to 2009 were selected from a clinical cohort with abstracted pregnancy and placental pathology data to undergo transthoracic echocardiography (2017 to 2020). Medical history, blood pressure, and weight were measured at the study visit.

RESULTS

The authors enrolled 132 women (10 ± 1 years post-delivery, age 38 ± 6 years): 102 with normotensive pregnancies and 30 with HDP: pre-eclampsia (n = 21) or gestational hypertension (n = 9). Compared with women with normotensive pregnancies, those with HDP history were more likely to have current hypertension (63% vs. 26%; p < 0.001). After adjusting for age, race, MVM lesions, body mass index, current hypertension, and hemoglobin A1c, women with HDP history had higher interventricular septal thickness (β = 0.08; p = 0.04) and relative wall thickness (β = 0.04; p = 0.04). In subgroup analyses, those with both HDP history and current hypertension had a higher proportion of left ventricular remodeling (79.0%) compared with all other groups (only HDP [36.4%; p = 0.01], only current hypertension [46.2%; p = 0.02], and neither HDP nor hypertension [38.2%; p < 0.001]), and lower mitral inflow E/A and annular e'. Accounting for placental MVM lesions did not impact results.

CONCLUSIONS

Women with both HDP history and current hypertension have pronounced differences in left ventricular structure and function a decade after pregnancy, warranting continued surveillance and targeted therapies for cardiovascular disease prevention.

Cardiovascular Health After Preeclampsia: Patient and Provider Perspective

Background: Preeclampsia predicts future cardiovascular disease (CVD) yet few programs exist for post-preeclampsia care. Methods: The Health after Preeclampsia Patient and Provider Engagement Network workshop was convened at the Radcliffe Institute for Advanced Study in June 2018. The workshop sought to identify: 1) patient perspectives on barriers and facilitators to CVD risk reduction; 2) clinical programs specialized in post-preeclampsia care; 3) recommendations by national organizations for risk reduction; and 4) next steps. Stakeholders included the Preeclampsia Foundation, patients, clinicians who had initiated CVD risk reduction programs for women with prior preeclampsia, researchers, and national task force members. Results: Participants agreed there is insufficient awareness and action to prevent CVD after preeclampsia. Patients suggested a clinician checklist to ensure communication of CVD risks, enhanced training for clinicians on the link between preeclampsia and CVD, and a post-delivery appointment with a clinician knowledgeable about this link. Clinical programs primarily served patients in the first postpartum year, bridging obstetrical and primary care. They recommended CVD risk modification with periodic blood pressure, weight, lipid and diabetes screening. Barriers included the paucity of programs designed for this population and gaps in insurance coverage after delivery. The American Heart Association, the American College of Obstetricians and Gynecologists, and the Preeclampsia Foundation have developed guidelines and materials for patients and providers to guide management of women with prior preeclampsia. Conclusions: Integrated efforts of patients, caregivers, researchers, and national organizations are needed to improve CVD prevention after preeclampsia. This meeting's recommendations can serve as a resource and catalyst for this effort.

Be Healthe for Your Heart: A Pilot Randomized Controlled Trial Evaluating a Web-Based Behavioral Intervention to Improve the Cardiovascular Health of Women with a History of Preeclampsia

This pilot randomized controlled trial (RCT) aimed to determine the acceptability and preliminary efficacy of a web-based cardiovascular disease (CVD) prevention intervention for women following preeclampsia. Australian women with a recent history (≤4 years post diagnosis) of preeclampsia were randomized into two study arms: (1) Be Healthe for your Heart, a web-based behavioral intervention or; (2) Control, access to the National Heart Foundation website. Assessments were conducted at baseline, and after three months. Intervention acceptability and impact on absolute CVD 30-year risk score, CVD risk markers and health behaviors were assessed. Twenty-four of 31 (77.4%) women completed the three-month assessment. Eleven out of 13 intervention participants (84.6%) agreed/strongly agreed they were satisfied with the program, with a mean score of 4.2 ± 0.9 (maximum of five). There were no significant between or within group differences in absolute CVD risk, CVD risk markers or health behaviors from baseline to three months. Women with a history of preeclampsia were successfully recruited and retained and they reported high levels of acceptability with the Be Healthe for your Heart program. Further research is therefore needed from powered trials to determine the impact of web-based lifestyle interventions on CVD risk in this at-risk group.

Blood pressure postpartum (BP2) RCT protocol: Follow-up and lifestyle behaviour change strategies in the first 12 months after hypertensive pregnancy

OBJECTIVES

Women who had hypertensive disorders of pregnancy (HDP) are twice as likely to experience maternal cardiovascular disease later in life. The primary aim of this study (BP²) is to compare outcomes of 3 different management strategies, including lifestyle behaviour change (LBC), in the first 12 months postpartum in women who had HDP in their preceding pregnancy. Secondary aims include assessing the effects on other cardiometabolic parameters.

STUDY DESIGN

Three-arm multicentre randomised trial in metropolitan Australian hospitals, (registration: ACTRN12618002004246) target sample size 480. Participants are randomised to one of three groups: 1) Optimised usual care: information package and family doctor follow-up 6 months postpartum 2) Brief intervention: information package as per group 1, plus assessment and brief LBC counselling at a specialised clinic with an obstetric physician and dietitian 6 months postpartum 3) Extended intervention: as per group 2 plus enrolment into a 6 month telephone-based LBC program from 6 to 12 months postpartum. All women have an outcome assessment at 12 months.

MAIN OUTCOME MEASURES

Primary outcomes: (a) BP change or (b) weight change and/or waist circumference change.

SECONDARY OUTCOMES

maternal health-related quality of life, engagement and retention in LBC program, biochemical markers, vascular function testing, infant weight trajectory, incremental cost-effectiveness ratios. The study is powered to detect a 4 mmHg difference in systolic BP between groups, or a 4 kg weight loss difference/2cm waist circumference change.

CONCLUSIONS

BP² will provide evidence regarding the feasibility and effectiveness of postpartum LBC interventions and structured clinical follow-up in improving cardiovascular health markers after HDP.

Provider Counseling About and Risk Perception for Future Chronic Disease Among Women with Gestational Diabetes and Preeclampsia

Background: Women diagnosed with gestational diabetes or preeclampsia are at a greater risk of developing future type 2 diabetes mellitus, high blood pressure, and cardiovascular disease. Increased perception of future chronic disease risk is positively associated with making health behavior changes, including in pregnant women. Although gestational diabetes is a risk factor for type 2 diabetes, few women have heightened risk perception. Little research has assessed receipt of health advice from a provider among women with preeclampsia and its association with risk perception regarding future risk of high blood pressure and cardiovascular disease. Among women with recent diagnoses of preeclampsia or gestational diabetes, we assessed associations between receipt of health advice from providers, psychosocial factors, and type of pregnancy complication with risk perception for future chronic illness. Methods: We conducted a cross-sectional analysis among 79 women diagnosed with preeclampsia and/or gestational diabetes using surveys and medical record abstraction after delivery and at 3 months postpartum. Results: Overall, fewer than half of the 79 women with preeclampsia and gestational diabetes reported receiving health advice from a provider, and women with preeclampsia were significantly less likely to receive counseling as compared with women with gestational diabetes (odds ratio 0.23). We did not identify a difference in the degree of risk perception by pregnancy complication or receipt of health advice. There were no significant differences in risk perception based on age, race, education, or health insurance coverage. Conclusions: We demonstrated that women with preeclampsia and gestational diabetes are not routinely receiving health advice from providers regarding future chronic disease risk, and that women with preeclampsia are less likely to be counseled on their risk, compared with women with gestational diabetes. Provider and patient-centered interventions are needed to improve postpartum care and counseling for women at high risk for chronic disease based on recent pregnancy complications.

Hypertensive Disorders of Pregnancy and Future Maternal Health: How Can the Evidence Guide Postpartum Management?

PURPOSE OF REVIEW

To review the postpartum management of hypertensive disorders of pregnancy.

RECENT FINDINGS

Hypertensive disorders are associated with an increased risk of future cardiovascular disease; however, there is a poor understanding of the underlying mechanisms and few recommendations to guide care in the postpartum period. Recent studies have shown high rates of masked hypertension and home blood pressure monitoring in the first year postpartum may be a promising opportunity to monitor health given evidence of high maternal adherence to this approach. In longer term, women with a history of a hypertensive disorder of pregnancy have higher blood pressures, increased risk of metabolic syndrome, and perhaps excess diastolic dysfunction. Triaging risk and improving handoff from the obstetrician to the primary care provider or subspecialist should be a priority in this population. Hypertensive disorders of pregnancy remain an untapped opportunity to identify excess cardiovascular risk in affected women at a time when mitigating that risk during the reproductive years has the potential to improve future pregnancy health as well as improve women's long-term cardiometabolic health.

Postpartum Interventions to Reduce Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: A Systematic Review

Introduction: Hypertensive disorders (HDP) affect ~7% of pregnancies. Epidemiological evidence strongly suggests HDP independently increases that individual's risk of later cardiovascular disease (CVD). Focus on reduction or mitigation of this risk has been limited. This review seeks to identify trialed interventions to reduce cardiovascular risk after HDP. Methods: Online medical databases were searched to identify full-text published results of randomized controlled trials (RCT) in women <10 years postpartum after HDP that trialed interventions to reduce cardiovascular risk. Outcomes sought included cardiovascular disease events, chronic hypertension, and other measures of cardiovascular risk such as obesity, smoking status, diet, and physical activity. Publications from January 2008 to July 2019 were included. Results: Two RCTs were identified. One, a trial of calcium vs. placebo in 201 women with calcium commenced from the first follow-up visit outside of pregnancy and continued until 20 weeks' gestation if another pregnancy occurred. A non-significant trend toward decreased blood pressure was noted. The second RCT of 151 women tested an online education programme (vs. general information to control group) to increase awareness of risk factors and personalized phone-based lifestyle coaching in women who had a preeclampsia affected pregnancy in the 5 years preceding enrolment. Significant findings included increase in knowledge of CVD risk factors, reported healthy eating and decreased physical inactivity, however adoption of a promoted heart healthy diet and physical activity levels did not differ significantly between groups. Several observational studies after HDP, and one meta-analysis of studies of lifestyle interventions not performed specifically after HDP but used to extrapolate likely benefits of lifestyle interventions, were identified which supported the use of lifestyle interventions. Several ongoing RCTs were also noted. Discussion: There is a paucity of intervention trials in the early years after HDP to guide evidence-based cardiovascular risk reduction in affected women. Limited evidence suggests lifestyle intervention may be effective, however degree of any risk reduction remains uncertain. Conclusion: Sufficiently powered randomized controlled trials of appropriate interventions (e.g., lifestyle behavior change, pharmacological) are required to assess the best method of reducing the risk of cardiovascular disease in this at-risk population of women.

Be Healthe for Your Heart: Protocol for a Pilot Randomized Controlled Trial Evaluating a Web-Based Behavioral Intervention to Improve the Cardiovascular Health of Women With a History of Preeclampsia

Background: Women with a history of preeclampsia are at greater risk of cardiovascular disease (CVD) related morbidity. Despite this knowledge, there is a lack of interventions available for women with a history of preeclampsia for the prevention of CVD. The aim of this pilot randomized controlled trial (RCT) is to determine the acceptability and preliminary efficacy of a web-based behavioral intervention targeted to women with a history of preeclampsia (Be Healthe for your Heart). Method: Australian women aged 18-45 years, with a recent history (≤4 years post diagnosis) of preeclampsia will be recruited for a 3-months, 2-arm parallel group pilot RCT. Participants will be randomized into 2 study arms: (1) Be Healthe for your Heart or; (2) Control, with assessments conducted at baseline, and after 3-months. Be Healthe for your Heart is an intervention delivered online via the program website, with weekly emails to support changes in modifiable CVD risk factors (excess body weight, physical inactivity, poor diet, and stress), using behavior change techniques (e.g., self-monitoring, goal setting). Intervention acceptability (satisfaction, usability, appropriateness, and usage) and impact on absolute full CVD 30-years risk score, CVD risk markers, and modifiable risk factors will be assessed. Discussion: No studies to date have evaluated acceptability and preliminary efficacy of a web-based intervention for the prevention of CVD in this high-risk population with preeclampsia. This pilot trial will inform development of a fully powered RCT if acceptability and preliminary efficacy are demonstrated.