Preeclampsia threatens the lives of as many as 8 percent of pregnant women across the country from year to year. It is such a serious condition that an entire foundation was formed to advocate for women who have survived and those still at risk, as well as to provide education to healthcare providers and the general public. A recent mention in the period drama “Downtown Abbey” spiked public interest in the disorder, and many are becoming more informed about the condition. Both SCAI’s public education website, www.SecondsCount.org, and the Preeclampsia Foundation’s website, www.preeclampsia.org, experienced a boon of traffic, but there are still others–even physicians–who don’t know about the connection between preeclampsia and cardiovascular disease (CVD).
Heart disease is already the leading cause of death in women, but women who develop preeclampsia during pregnancy could be two times as likely to develop heart disease or suffer stroke in the 5–10 years following pregnancy. Even if symptoms improve and there are no more signs of disease for the rest of their childbearing years, increased risk for CVD lurks in the background until later in life. Risk accumulates especially in women who have had multiple pregnancies affected by preeclampsia, preterm births or low birth weight. These women may be seven times as likely to eventually require hospitalization and die from coronary artery disease.
“Even in our own organization’s history, our whole focus has been on preeclampsia as a complication of pregnancy,” said Eleni Tsigas, executive director of the Preeclampsia Foundation and a two-time preeclampsia survivor. “It has become apparent as this research has become unequivocal that it is not just a pregnancy issue. If we are going to be true to our mission to reduce the burden of disease of preeclampsia, we have to look at this as a life-course event and care about women long after pregnancy.”
Rooting out the Cause
Researchers have been hashing out whether preeclampsia spelled subsequent CVD since the 1960s, said Roxana Mehran, M.D., FSCAI, professor of Medicine and Health Policy and director of Interventional Cardiovascular Research and Clinical Trials at Mount Sinai School of Medicine in New York City, and chair of SCAI’s Women in Innovations (SCAI-WIN) program. Many studies have now established the risk, but what is still not understood, even today, is the genesis of CVD following preeclampsia.
“The pathobiology is probably extremely complex,” said Dr. Mehran. “We need to work harder on this issue. We have to understand and follow these women more carefully. A lot of the time, pregnancy complications happen, the baby comes, and everybody is happy. The women are young and they totally forget that they even had any of these important complications.”
Ellen Seely, M.D., director of Clinical Research and the endocrinology, diabetes and hypertension division at Brigham and Women’s Hospital and a professor of Medicine at Harvard Medical School in Boston, outlined two schools of thought regarding the origins of preeclampsia-related CVD. One is that women have preexisting risk and that increases in intravascular volume and insulin resistance and other defects in the homeostatic system can unmask risk for CVD. Another is that preeclampsia intrinsically causes vascular and endothelial damage that can be permanent, resulting down the line in serious cardiovascular events such as myocardial infarction and stroke.
“A lot of people think it may be a combination of the two, that there is a predisposition that is being unmasked during pregnancy, and that preeclampsia itself may also exacerbate that predisposition,” explained Dr. Seely. “Either way, preeclampsia is creating a window into future CVD. You have this time period where the women have only subclinical manifestations of CVD and sometimes very subtle ones where you could intervene with this group of women to decrease their risk.”
Educating Women and Their Physicians
The major risk factors associated with preeclampsia are almost identical to those for CVD. “Women with preeclampsia and women who develop CVD are usually heavier, and have increased lipids, and since the cardiometabolic profiles appear similar, what we recommend is that traditional cardiovascular risk factors get addressed,” said Dr. Seely.
Part of the challenge of bridging the gap between preeclampsia care and follow-up cardiovascular assessment is connecting obstetricians with primary caregivers and cardiologists. OB/GYN physicians can help by spreading the word whenever possible. Dr. Seely added that more collaboration has been happening across specialties over the past 5-10 years and will likely continue.
“Given these patients see midwives and obstetricians more often during pregnancy, these individuals, as the first point of contact, would be best suited to educate patients on the future cardiovascular risks of preeclampsia or even consider referral to specialists, such as cardiologists, for further treatment. Paying attention to simple things in these women can play a huge impact on whether they go on to develop serious CVD in the future. We know that in most cases CVD – in particular coronary disease and stroke – can be prevented with appropriate care of risk factors. It is important women who have experienced preeclampsia have their blood pressure, cholesterol, and blood sugar measured on a regular basis,” noted Vijay Kunadian, M.D., FSCAI, an interventional cardiologist and senior lecturer at Newcastle University in Newcastle upon Tyne, United Kingdom, an editor for SCAI’s SecondsCount.org and a member of SCAI-WIN.
Preeclampsia can also affect the children born to preeclamptic women, added Dr. Kunadian. “Some studies suggest that children born to preeclamptic women can develop raised blood pressure as early as 9–12 years old. The children are also at risk for coronary artery disease and stroke in their adult life. This is why it is important that pediatricians are aware so that they monitor the children for raised blood pressure.”
WIN Screening and Early Intervention
In her role as the chair of SCAI-WIN, Dr. Mehran has been integrally involved in an ongoing pilot study that screens women for cardiovascular risk during OB/GYN appointments. Launched by SCAI-WIN and Abbott’s Women’s Heart Health Initiative, the study involved 3,000 women completing a simple questionnaire on a wide variety of risk factors. Results from the first phase of the study showed that 80 percent of responders had at least one risk factor for CVD.
“I think we accomplished our objective, which was to, in a very effective way, screen women for CVD when they are going for their GYN follow-up,” Dr. Mehran said. “We think we could also do this in breast mammography suites, which is our next step.”
If the major preventive interventions available to women at increased risk are the same as those for general CVD, then the goal is healthy eating, smoking cessation, controlled cholesterol, weight loss and physical activity. Public efforts to engender these lifestyle changes in the general population have not been effective, but those at increased risk are more likely to be self-aware and listen to their doctors. Other than lifestyle changes, little research has been conducted to determine the best clinical interventions, whether specific revascularization strategies or pharmacological means, should be used to treat these women. Further studies are on the horizon, said Dr. Mehran.
All the Right Tools
The good news is that the connection is being established at all levels. Guidelines published by the American Heart Association in 2011 include pregnancy complications such as preeclampsia as a risk factor for CVD and noted that the condition was equivalent to a failed stress test.
Another next step, said Dr. Mehran, is to get pregnancy complications like preeclampsia on primary care medical history questionnaires. These should prompt women to reveal the number of pregnancies they’ve had, whether high blood pressure or gestational diabetes was an issue, as well as whether babies were born early or underweight. Other possibilities for patient education include the Preeclampsia Foundation’s online toolkit, potential iPhone-apps and web applications similar to those that have worked for gestational diabetes encouraging lifestyle modification from the comforts of home.
With everyone working together–OB/GYNs, primary doctors, cardiologists, and preeclampsia advocates–women at increased risk will have a much better chance of avoiding serious cardiovascular events post-preeclampsia and get the care they need from specialists who understand the connection.
For more information about the SCAI-WIN program, visit http://bit.ly/10SPKH6, and to access SCAI’s public education resources on preeclampsia, visit www.SecondsCount.org.