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

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Hypertensive disorders of pregnancy (preeclampsia or gestational hypertension) (n=132). Intervention: History of hypertensive disorders of pregnancy (preeclampsia or gestational hypertension) vs. Normotensive index pregnancy. Primary outcome: Left ventricular remodeling (defined as relative wall thickness > 0.42) and LV interventricular septal/relative wall thickness at 8-10 years post-delivery (OR 3.2 (adjusted for age, race, and placental MVM lesions; attenuated to OR 2.5 after further adjustment for BMI, current hypertension, and HbA1c); β 0.08 for interventricular septal thickness and β 0.04 for relative wall thickness, 95% CI 1.2-8.5, p=0.02).

Q: What does this research mean for the field?

A history of hypertensive disorders of pregnancy is associated with increased left ventricular wall thickness and adverse remodeling nearly a decade after delivery, with the highest risk observed in women who have also developed current hypertension. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Malamo E. Countouris; Flordeliza S. Villanueva; Kathryn L. Berlacher; João L. Cavalcante; William Tony Parks; Janet M. Catov

doi:10.1016/j.jacc.2020.12.051

February 22, 2021Journal of the American College of CardiologyOpen Access

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

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Key result

Hypertensive disorders of pregnancy linked to ~3.2-fold higher odds of midlife LV remodeling.

OR 3.2 (adjusted for age, race, and placental MVM lesions; attenuated to OR 2.5 after further adjustment for BMI, current hypertension, and HbA1c); β 0.08 for interventricular septal thickness and β 0.04 for relative wall thickness
95% CI 1.2-8.5
P=0.02
n=132

Why the study?

Hypertensive disorders of pregnancy are associated with short-term cardiac structure and function abnormalities, but later-life echocardiographic changes and the effects of placental maternal vascular malperfusion lesions or current hypertension are not well studied.

Is a history of hypertensive disorders of pregnancy associated with adverse left ventricular remodeling and functional echocardiographic differences 8–10 years after delivery compared with normotensive pregnancies?

Key Points

To determine whether hypertensive disorders of pregnancy are associated with left ventricular echocardiographic abnormalities 8 to 10 years after delivery.
Selected 132 women (10±1 years post-delivery, age 38±6 years; 102 normotensive, 30 with HDP including 21 preeclampsia and 9 gestational hypertension) delivered between 2008 and 2009 from a clinical cohort.
Performed transthoracic echocardiography between 2017 and 2020 alongside clinical evaluations, blood pressure measurements, and pregnancy/placental pathology reviews.
Women with prior HDP had higher rates of current hypertension (63 vs 26%; p<0.001) and, after adjusting for age, race, MVM lesions, BMI, current hypertension, and HbA1c, had higher interventricular septal thickness (β 0.08; p=0.04) and relative wall thickness (β 0.04; p=0.04).
Those with both HDP history and current hypertension had the highest proportion of LV remodeling (79.0%) compared to HDP alone (36.4%; p=0.01), current hypertension alone (46.2%; p=0.02), and neither condition (38.2%; p<0.001).
Accounting for placental maternal vascular malperfusion lesions did not significantly alter echocardiographic outcomes.

Study Design

Type

Cohort (n=132)

Blinding

Assessor-blinded (pathologist, sonographer, and interpreting cardiologists blinded to obstetric/clinical history)

Multicenter

No

Structured PICO

Is a history of hypertensive disorders of pregnancy associated with adverse left ventricular remodeling and functional echocardiographic differences 8–10 years after delivery compared with normotensive pregnancies?

P

Population

132 women (mean age 38-39 years, 100% female) from a US clinical cohort with placental pathology data available, free of pre-pregnancy hypertension or cardiovascular disease, evaluated 8-10 years after delivery.

E

Exposure

History of hypertensive disorders of pregnancy (HDP), including preeclampsia (elevated blood pressure plus proteinuria, n=21) or gestational hypertension (systolic blood pressure >140 mmHg or diastolic >90 mmHg diagnosed after 20 weeks gestation, n=9), further stratified by current hypertension and placental maternal vascular malperfusion (MVM) lesions.

C

Comparator

Women with normotensive index pregnancies (n=102) from the same clinical cohort.

O

Outcome

Echocardiographic measures of left ventricular (LV) structure and remodeling 8–10 years after delivery, specifically interventricular septal (IVS) thickness, relative wall thickness (RWT), and LV remodeling (defined as RWT > 0.42), assessed via 2D transthoracic, Doppler, and speckle-tracking strain echocardiography.surrogate

Main Result

Odds Ratio: 3.2 (95% CI 1.2–8.5)

p-value: p=0.02

Women with a history of hypertensive disorders of pregnancy and subsequent chronic hypertension exhibit a nearly 80% prevalence of adverse left ventricular remodeling and worse diastolic function a decade after delivery, highlighting a high-risk subgroup needing targeted cardiovascular surveillance and early preventive therapy.

Limitations

Relatively small sample size from a single center
HDP diagnosis obtained by chart abstraction using definitions at the time of delivery, and unable to precisely account for all HDP occurrences in non-index pregnancies
Control group had clinical indications for placental pathology evaluation at delivery and thus may not represent entirely normal pregnancies
Suboptimal echocardiographic image quality prevented measurement of LV global longitudinal strain in 14% and RV strain in 27% of participants
HDP diagnosis was obtained by chart abstraction for the index pregnancy and 60% of subsequent births, preventing precise accounting for all HDP occurrences in non-index pregnancies
HDP was defined by criteria at the time of delivery rather than newer definitions, and the recurrent HDP group (n=3) was too small to evaluate
Control group had clinical indications for placental pathological evaluation at delivery and thus may not have had entirely normal pregnancies
RV strain data analysis was limited by suboptimal image quality in almost 30% of participants (27%) and lack of dedicated RV strain software

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Implication

Women with hypertensive pregnancy disorders plus current hypertension show high LV remodeling; extends prior associations but leaves open surveillance value.

Abstract

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: We aim to determine if HDP is associated with echocardiographic differences 8–10 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 2008–2009 were selected from a clinical cohort with abstracted pregnancy and placental pathology data, to undergo transthoracic echocardiography (2017–2020). Medical history, blood pressure, and weight were measured at the study visit. Results: We enrolled 132 women (10±1 years post-delivery, age 38±6 years): 102 with normotensive pregnancies and 30 with HDP; preeclampsia (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, BMI, current hypertension, and HbA1c 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 LV remodeling (79.0%) compared with all other groups (only HDP [36.4%; p=0.01], only current hypertension [46.2%; p =0.02], 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 LV structure and function a decade after pregnancy, warranting continued surveillance and targeted therapies for CVD prevention.

Discussion

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Cite This Study

Countouris et al. (2021) conducted a cohort in Hypertensive disorders of pregnancy (preeclampsia or gestational hypertension) (n=132). History of hypertensive disorders of pregnancy (preeclampsia or gestational hypertension) vs. Normotensive index pregnancy was evaluated on Left ventricular remodeling (defined as relative wall thickness > 0.42) and LV interventricular septal/relative wall thickness at 8-10 years post-delivery (OR 3.2 (adjusted for age, race, and placental MVM lesions; attenuated to OR 2.5 after further adjustment for BMI, current hypertension, and HbA1c); β 0.08 for interventricular septal thickness and β 0.04 for relative wall thickness, 95% CI 1.2-8.5, p=0.02). Hypertensive disorders of pregnancy were associated with higher LV septal (β 0.08, p=0.04) and relative wall thickness (β 0.04, p=0.04) and 79.0% LV remodeling when combined with current hypertension.

synapsesocial.com/papers/6af3897e3b0cd44ded5db5b9 https://doi.org/10.1016/j.jacc.2020.12.051

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

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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