Long-term cardiovascular outcomes following hypertensive disorders of pregnancy: a systematic review and meta-analysis of 13.6 million women

Background Hypertensive disorders of pregnancy (HDP), including preeclampsia, gestational hypertension, and eclampsia, complicate up to 10% of pregnancies and are increasingly recognized as female-specific cardiovascular risk factors. However, the magnitude, timing, and hierarchy of long-term cardiovascular risk—including heart failure, ischemic heart disease, stroke, and cardiovascular mortality—remain incompletely quantified across large-scale populations. Purpose To quantify the long-term risk of heart failure, ischemic heart disease, stroke, and cardiovascular mortality following hypertensive disorders of pregnancy compared with normotensive pregnancies. Methods We conducted a systematic review and meta-analysis of observational cohort studies evaluating long-term cardiovascular outcomes after hypertensive disorders of pregnancy (HDP). Databases were systematically searched from inception through December 2025. Adjusted risk estimates (RR/HR) were pooled using random-effects models. Subgroup and sensitivity analyses were performed by HDP subtype and follow-up duration. Results A total of 74 observational cohort studies comprising 13,582,607 women were included (mean age at pregnancy 28.4 years; mean follow-up 14.2 years). Exposure cohorts included women with a history of preeclampsia (n=645,212), gestational hypertension (n=312,890), and eclampsia (n=18,455), compared to normotensive controls (n=12,606,050). For the primary endpoint of heart failure, HDP demonstrated the highest risk elevation versus normotensive pregnancy (RR 3.16; 95% CI 2.53–3.95). Subgroup analysis revealed that the risk was most pronounced following eclampsia (RR 4.19; 95% CI 2.01–8.72). For ischemic heart disease, women with prior HDP showed a significantly increased long-term risk (RR 2.16; 95% CI 1.86–2.52), with the risk persisting across both 10-year and 20-year follow-up intervals. Regarding cerebrovascular outcomes, HDP was associated with a nearly two-fold increase in stroke risk (RR 1.81; 95% CI 1.52–2.15). Sensitivity analysis indicated that the risk for stroke was highest in the first decade postpartum (RR 2.45; 95% CI 1.60–3.74) compared to later years. For cardiovascular mortality, a history of HDP was associated with a significant increase in the hazard of death (HR 1.49; 95% CI 1.05–2.10). Hierarchy of risk severity placed eclampsia highest for all-cause CV events, followed by preeclampsia and gestational hypertension. Consistency across large-scale cohorts suggests that HDP serves as a potent, female-specific independent risk factor for premature cardiovascular morbidity. Conclusion Hypertensive disorders of pregnancy confer a substantial and persistent increase in long-term cardiovascular morbidity and mortality, underscoring their role as powerful female-specific predictors of premature cardiovascular disease.