Women who have complications during pregnancy – such as high blood pressure or gestational diabetes – have a significantly higher risk for deadly heart disease. Why this should serve as a wake-up call.
The findings, along with several studies and commentaries focused on research in women, are featured in a special Go Red for Women Spotlight issue of Circulation. The analyses identify a substantial number of cardiovascular risk factors specific to or predominant in women, discuss the need to raise awareness of heart disease as a major health risk for women, and emphasize the need for prevention strategies to reduce adverse cardiovascular outcomes and achieve health equity, particularly among women from diverse racial and ethnic groups or underrepresented communities.
The new scientific statement from the American Heart Association, “Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk Following Adverse Pregnancy Outcomes,” summarizes the current evidence about how to manage heart disease risk factors during pregnancy and promote cardiovascular health in women after delivery using the AHA’s Life Essential 8 cardiovascular health metrics as a framework.
An estimated 10–20 % of women experience pregnancy complications, such as high blood pressure, gestational diabetes and/or preterm birth (delivery before 37 weeks). These complications often arise due to metabolic and vascular changes during pregnancy. Adverse pregnancy outcomes are becoming increasingly common and are considered significant risk factors for future long-term complications, including increased lifetime risk of heart disease, heart failure, stroke, chronic kidney disease or vascular dementia.
Additional findings in the statement include:
Jennifer Lewey, M.D., chair of the writing group for the scientific statement, said: “Despite these well-established associations, little is known about the care that may best reduce cardiovascular risk in women who had pregnancy complications, and what efforts may be appropriate to reduce their long-term heart disease risk and optimize cardiovascular health throughout their lifespan. Pregnant and postpartum women have traditionally been excluded from clinical trials, and, therefore, we have far less evidence to help guide their care.”
According to the statement, early detection and treatment of heart disease risk factors, such as high blood pressure, Type 2 diabetes and high cholesterol, after pregnancy may help prevent future heart attack, heart failure and stroke, especially among those who have experienced one or more complications during pregnancy.
“Adverse pregnancy outcomes can be a wake-up call to a young person that they may be at risk for heart disease and stroke later in life. By identifying these women at a younger age, we will be able to act earlier to prevent and treat risk factors and promote healthy lifestyle changes,” said Lewey, who is director of the Penn Women’s Cardiovascular Health Program and an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine in Philadelphia.
Social determinants of health, such as race and ethnicity, socioeconomic status, and geography (rural vs. urban communities), also affect the prevalence of pregnancy complications and are key contributors to disparities in prenatal heart disease risk factors, access to care, and outcomes for both the mother and infant. Compared with white women, Black women are more likely to have sub-optimal measurements of cardiovascular health, including blood pressure, blood glucose levels and body mass index (BMI). Black women also have an increased risk of developing high blood pressure during pregnancy, the highest maternal mortality rates and a higher risk of heart disease across their life span.
The first year after delivery is a critical time to assess long-term heart disease risk and implement lifestyle changes and treatment, if needed, to improve heart health for women and reduce the risk of future pregnancy complications for individuals who plan on future pregnancies. In particular, health care in the fourth trimester tailored to support disorders of pregnancy, has great potential to improve cardiovascular health across the life course.
Strategies used to promote cardiovascular health in non-pregnant individuals may be successfully adapted to the postpartum period and improve cardiovascular health across a woman’s lifetime. These may include regular cardiovascular risk factor screening and treatment, ensuring transitions of care among obstetricians, primary care professionals, and health system and community-based interventions. However, many women face significant barriers in accessing primary care after delivery. Up to 40 % of women do not access postpartum care, and only an estimated 18 % to 25 % of postpartum patients with pregnancy complications or chronic health conditions are seen by a primary care clinician within 6 months of delivery.
Lifestyle interventions based on the AHA’s Life’s Essential 8 cardiovascular health metrics are urged to optimize heart health, particularly during the first 12 months after delivery. Evidence-based approaches that target achieving a healthy weight, healthy diet and regular physical activity can help reduce short- and long-term heart disease risks associated with adverse pregnancy complications.
In The Feminine Face of Heart Disease 2024, author and cardiovascular pioneer Nanette K. Wenger, M.D., provides a historical perspective on gender barriers in cardiology and identifies gender-specific differences in heart disease, including risk factors, progression of the disease, treatments, and outcomes specifically among women. “For most of the last century, heart disease was considered a problem for men, and women were believed to have cardioprotective benefits from female sex hormones such as estrogen,” said Dr. Wenger. “However, emerging evidence shows that there are a substantial number of heart disease risk factors that are specific to women or predominant in women.”
According to Wenger, there is also a presumption that heart disease symptoms in men are the implicit gold standard and cardiovascular symptoms in women are atypical. Even though heart disease is the leading cause of death for women, only 22 % of primary care physicians and 42 % of cardiologists in a nationwide survey reported that they felt prepared to address cardiovascular disease risk in women.
High blood pressure, a major risk factor for heart disease, accounts for 20 % of deaths in women, and obesity has a particularly high impact on the development of high blood pressure in women. Other gender-specific risk factors include:
Previous national educational advocacy programs improved awareness of heart disease as a major health risk for women, yet that awareness has decreased over the past decade. A 2019 survey found that most women were unable to identify the signs or symptoms of a heart attack, with recognition lowest among young Asian, Black and Hispanic women. These disparities in awareness of heart disease risk factors and knowledge of symptoms affect treatment strategies, which may lead to poorer outcomes.
Studies show the lifetime stroke risk is comparable for women and men, but women with ischemic stroke are less likely to be transported to the hospital by emergency medical services and to receive prompt imaging and blood thinners. Women are also more likely to die within 30 days of stroke hospitalization. Wenger said: “About 80–90 % of cardiovascular disease is preventable. Implementing preventive strategies early could have a significant impact on reducing premature cardiovascular disease, stroke, and related mortality for women.”
Public health interventions focused on social determinants of health are needed to optimize cardiovascular health across a woman’s life span. More research on cardiovascular prevention and treatment for women is needed, focusing on people in under-resourced communities.
This article is based on a press release by the BMJ. You can find the original publication here and by following the link in our text.
Image source: Camila Cordeiro, Unsplash
