A prediction model combining clinical and peripartum cardiovascular screening features can effectively identify persistent hypertension in patients with a history of hypertensive disorders of pregnancy (HDP). These findings were published in the Journal of the American College of Cardiology.
Researchers aimed to evaluate the effectiveness of peripartum screening in predicting chronic hypertension following HDP.
They conducted a longitudinal observational prospective cohort study at St George’s University Hospitals NHS Foundation Trust, London, United Kingdom between February 2019 and August 2021. The study authors consecutively recruited 211 women with pregnancies complicated by HDP, who received peripartum transthoracic echocardiography (TTE) and were evaluated for chronic hypertension (defined as blood pressure ≥140/90 mm Hg or being on antihypertensive medication) at least 3 months postpartum. Maternity databases, discharge letters, and direct patient enquiry provided pregnancy data and outcomes.
Exclusion criteria included known cardiac conditions and pregnancies complicated by fetal abnormalities or genetic syndromes. The researchers found that 33.2% of the patients remained hypertensive at a median postpartum follow-up of 124 days (IQR, 103-145 days). They identified 6 cases of white-coat syndrome and included those results in the hypertensive group. Of these patients, 63.5% had persistent left ventricular (LV) myocardial dysfunction or hypertension on postpartum TTE. LV myocardial dysfunction at the postpartum assessment was found in 48.8% of patients, who showed worse cardiac indices compared with women with normal myocardial function.
The researchers noted that women with chronic hypertension vs women who were normotensive were more likely to be Afro-Caribbean (27.1% vs 7.8%; P <.0001), older (35.5 [SD, 5.0] years vs 32.9 [SD, 5.6] years; P =.001), had higher mean arterial pressure (106.5 [SD, 8.4] mm Hg vs 103.3 [SD, 7.0] mm Hg; P =.004), and had higher body mass index (33.41 [SD, 5.94] vs 31.15 [SD, 5.35]; P =.006).
The researchers further observed that women with chronic hypertension vs women who were normotensive showed significantly higher relative wall thickness (0.46 [SD, 0.08] vs 0.40 [SD, 0.09]; P <.0001), LV mass index (84.30 [SD, 17.88] g/m2 vs 76.31 [SD, 14.83] g/m2; P =.001), and lower global longitudinal strain (-15.58% [SD, 2.74%] vs -16.55% [SD, 2.16%]; P =.006).
A prediction model was then calculated by combining the following echocardiographic and clinical features:
- LV mass index greater than 75 g/m2
- Relative wall thickness greater than 0.42
- E/e’ ratio greater than 7
- First trimester mean arterial pressure
- Maternal age
This calculation showed excellent accuracy identifying women with persistent hypertension after HDP (area under the curve, 0.85; 95% CI, 0.79-0.90).
Study limitations include the single-center design and that there is no adjustment for different types of antihypertensive treatment used in pregnancy and postpartum period. There is also a short postpartum follow-up and no measurement of left atrial reservoir strain.
“Peripartum cardiovascular screening, including maternal TTE, could effectively identify women with HDP at increased risk of persistent postpartum hypertension or asymptomatic LV myocardial dysfunction,” the study authors wrote. They urge more intensive blood pressure monitoring and early therapeutic interventions. They believe achieving blood pressure control and improving cardiac remodeling could reduce future risk for cardiovascular diseases.
Giorgione V, Khalil A, O’Driscoll J, Thilaganathan B. Peripartum screening for postpartum hypertension in women with hypertensive disorders of pregnancy. J Am Coll Cardiol. Published online October 3, 2022. doi:10.1016/j.jacc.2022.07.028