Life’s Essential 8 in Pregnancy and Time to Incident Cardiometabolic Disease Over 7 Years Follow-Up

Importance: Assessment of cardiovascular health (CVH) during pregnancy may unmask latent metabolic vulnerability and indicate long-term disease risk. However, the prognostic value of the American Heart Association's Life's Essential 8 (LE8) framework during pregnancy remains uncertain. Objective: To evaluate CVH during pregnancy using a modified LE8 (mLE8) score in association with time to incident cardiometabolic disease. Design, Setting, and Participants: This cohort study used electronic medical record (EMR) surveillance for 7 years post partum (August 2018 to March 2026) and included singleton pregnancies in individuals aged 18 to 44 years without preexisting diabetes or cardiovascular disease (CVD) from a large academic medical system in South Carolina. Data were analyzed from December 2024 to April 2026. Exposures: A 7-component mLE8 score assessed during pregnancy, incorporating hypertensive disorders of pregnancy (HDP), 50 g glucose tolerance test results, early pregnancy body mass index, smoking status, sleep adequacy, diet quality, and physical activity. Scores ranged from 0 to 100, with higher scores indicating more favorable CVH. Main Outcomes and Measures: Postdelivery incident cardiometabolic conditions captured through EMRs and classified as chronic hypertensive conditions, chronic metabolic conditions (eg, dyslipidemia, impaired glucose regulation), and CVD (eg, cardiac arrest, cardiomyopathy). Adjusted accelerated time-to-failure models estimated mLE8 associations with incident conditions. Time to incident diagnosis was measured in days from delivery. Results: Among 1225 pregnancies (mean [SD] age, 25.0 [5.3] years), 499 incident cardiometabolic events occurred over a median (IQR) follow-up of 6.2 (2.8) years. Each 10-point higher mLE8 score was associated with a longer time to incident diagnosis of chronic hypertensive conditions (time ratio [TR], 1.26; 95% CI, 1.11-1.42) and chronic metabolic conditions (TR, 1.20; 95% CI, 1.11-1.29). Healthier HDP (1.06 [1.03-1.10]), glucose (1.15 [1.10-1.21]), body mass index (1.07 [1.04-1.11]), and sleep (1.05 [1.00-1.09]) scores were associated with longer time to diagnosis of chronic metabolic conditions. Associations were generally similar after excluding individuals with gestational diabetes or HDP. Conclusions and Relevance: In this cohort study of 1225 pregnancies, better CVH during pregnancy was associated with a longer time to incident postdelivery diagnosis of cardiometabolic conditions. Pregnancy-based CVH assessment may help identify individuals with elevated and emerging cardiometabolic risk who could benefit from early, targeted intervention and enhanced longitudinal surveillance.