Gestational HTN, Other High-BP States in Pregnancy Raise Later CV, Renal Risks

February 15, 2013

HELSINKI, Finland — A range of different high blood-pressure conditions of pregnancy predicted onset of cardiovascular events, chronic kidney disease (CKD), and diabetes over the subsequent decades, to varying degrees, over an average of about 40 years in the Northern Finland Birth Cohort 1966 [1].

In particular, new-onset gestational hypertension (HTN) in about 10% of the cohort of >10 000 women was associated with triple the risk of later fatal MI, almost twice the risk of CKD, and 45% to 60% increased risks of ischemic heart disease, ischemic stroke, and diabetes compared with women who remained normotensive during pregnancy.

Those adjusted risks were still significantly increased in an analysis that excluded women with traditional CV risk factors.

Heart failure was significantly more likely over the follow-up among women who during pregnancy had isolated systolic HTN, gestational HTN, chronic HTN, or preeclampsia or eclampsia. Diabetes was also predicted by isolated systolic HTN and chronic HTN.

"Many reproductive-aged women already have cardiovascular risk factors, and pregnancy as a stressor may reveal their vulnerability as new-onset or worsening hypertension occurs during pregnancy," according to the authors, led by Dr Tuija Männistö (National Institute of Child Health and Human Development, Bethesda, MD). "This might suggest that their poor metabolic health, not hypertension, leads to increased chronic disease risk."

But even in the analysis of women without such CV risk factors as smoking, obesity, or advanced age, many of the risks remained significantly higher in those with many of the high-blood-pressure conditions, they write, "suggesting that hypertension during pregnancy has an independent effect on long-term risk."

In an editorial accompanying the group's analysis [2], both of which were published in the February 12, 2013 issue of Circulation, Drs Suttira Intapad and Barbara T Alexander (University of Mississippi Medical Center, Jackson) are especially impressed by the finding that nearly all of the studied high-blood-pressure conditions of pregnancy predicted postpartum onset of arterial hypertension, "even in the absence of prepregnancy risk factors such as obesity and smoking."

The guidelines include preeclampsia as a risk factor for heart disease and stroke, write the editorialists. Based on the current study, "the assessment of CV risk in women should be expanded to include all classifications of hypertension during pregnancy and not just those diagnosed clinically as preeclampsia."

Hazard Ratio (95% CI) for Postpregnancy Outcomes by High-Blood-Pressure Condition vs Normotensive During Pregnancy

Late outcome

Isolated systolic HTN

Gestational HTN

Preeclampsia or eclampsia

Chronic HTN

Any CV disease

1.14 (1.00–1.30)

1.45 (1.29–1.63)

1.40 (1.11–1.76)

1.66 (1.46–1.88)

Fatal MI

2.15 (1.35–3.41)

3.00 (1.98–4.55)

1.44 (0.51–4.08)

3.11 (2.05–4.74)

Heart failure

1.43 (1.13–1.82)

1.79 (1.43–2.21)

1.69 (1.12–2.56)

2.04 (1.64–2.55)

CKD

1.27 (0.72–2.25)

1.91 (1.18–3.09)

0.75 (0.17–3.38)

1.23 (0.67–2.24)

Diabetes

1.42 (1.13–1.78)

1.52 (1.21–1.89)

1.42 (0.92–2.19)

1.65 (1.31–2.07)

The authors note their calculations don't account for the intensity of any treatment for elevated blood pressure the women received during or after pregnancy and that more severe cases may have been more aggressively treated. "Given that those women still experienced high risk for chronic disease, if they received intensive treatment, our estimates of risk would be conservative."

The study was supported by the National Institutes of Health (NIH) and the Academy of Finland; the authors had no disclosures. Intapad discloses support from an American Heart Association postdoctoral fellowship grant and Alexander support from NIH grants.

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